The amount of the CMPs and assessments vary depending on the nature of the violation.
- The OIG may allocate penalties up to $10,000 for each item or service determined to be billed fraudulently. There could also be an assessment of up to three times the amount incorrectly billed.
- Example: A practice bills an ultrasound guidance incorrectly (which is defined as fraud by Medicare) 200 times and reimbursed $150 for each; the penalty has the potential to be $2,090,000.
- When there is a kickback violation, the OIG may allocate a penalty of $50,000 for each inappropriate act, which can levy up to three times the amount of the compensation paid.
- Example: A provider refers a patient to Lab ABC, in return the lab pays the physician $10 per person. The physician has referred a total of 100 patients; the penalty has the potential to be $5,003,000.
The OIG will determine how long a provider is on the LEIE; reinstatement is not automatic. Once the exclusion period is finished, the provider must complete and have a Statement and Authorization form notarized before the application will be reviewed.
To acquire the Statement and Authorization form, a provider has to make a request in writing to the OIG. After reviewing the form, the OIG will send the provider a written statement of its decision. Keep in mind, a provider can request to be reinstated within 90 days of the expiration of the exclusion. If the provider is denied, he or she can reapply for reinstatement in one year.
Ultimately, it is the physician’s responsibility to protect his or her practice. This can be done by verifying that staff and business associates are following the coding, billing, and compliance guidelines as outlined by the HHS. Information on practice management and coding can be located on the ACR website at www.rheumatology.org/practice, or contact the health policy department at (404) 633-3777.
Practice Pearl: Begin Preparation for ICD-10
Billing diagnosis codes will change October 1, 2013. Although it is 26 months away, the impact on physician practices will be so great that preparation should begin now. The ICD-10 conversion will touch every facet of physician practice systems, and there is no room for procrastination.
There are several steps practices can take to start getting ready:
- Conduct an impact analysis to identify the areas that will affected by ICD-10.
- Develop a financial analysis and budget for the cost of implementation.
- Create a communication plan to ensure that staff is informed on all areas of the transition.
- Develop an educational assessment and training plan for staff.
- Contact all vendors to verify their readiness for compliance.
Preparation for a smooth transition is important. Procrastination is not an option for physician practices. An action plan should be created to take the transition in phases. For more information on ICD-10 conversion and educational training, contact Antanya Chung at [email protected] or (404) 633-3777 ext. 818.
