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Barre EMS: Why CPIs Should Raise Legal Red Flags

Barre EMS: Why CPIs Should Raise Legal Red Flags

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Published by Craig Shibley
The following article appeared in the Journal of Emergency Medical Services in 2013. The author has more than three decades of combined field and legal experience.

Outsiders, use the CPI "road map" presented by Attorney Wolfberg and apply it to Wonderland 01005.

Now recall the MA AGO's Office's role in this affair... the Executive Office of Health & Human Services ... Powers & Sullivan ... and the Barre Emergency & Rescue Squad's Board of Directors.
The following article appeared in the Journal of Emergency Medical Services in 2013. The author has more than three decades of combined field and legal experience.

Outsiders, use the CPI "road map" presented by Attorney Wolfberg and apply it to Wonderland 01005.

Now recall the MA AGO's Office's role in this affair... the Executive Office of Health & Human Services ... Powers & Sullivan ... and the Barre Emergency & Rescue Squad's Board of Directors.

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Categories:Types, Legal forms
Published by: Craig Shibley on Feb 18, 2014
Copyright:Attribution Non-commercial

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08/22/2014

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Using “CPIs” to Help Prevent Legal Troubles
 
Monday, April 15, 2013 Douglas Wolfberg JD, EMT
The following article appeared in the © Journal of Emergency Medical Services. This article
should serve as a looking glass into Wonderland’s private, nonprofit Barre Emergency & Rescue
Squad Inc. and its peculiar relationship with the Town of Barre. Public records reveal a high transport record. All emergency runs. Receipts going to the
municipality’s police department. Poor record
-keeping. Private funds being invested by a public
entity…
 The Rescue Squad has refused to provide run reports filed with the Department of Public Health through its MATRIS System while incorrectly citing HIPPA laws as a blanket exemption. The Squad will never provide the information listed below, defined as Compliance Performance
Indicators (CPIs). However Health & Human Services OIG and IRS CI’s certainly have easy
access to all this
 
and more…
 
 
Many EMS managers are familiar with the concept of benchmarking. Whether used for monitoring and improving financial performance, clinical care or other key areas of EMS operations, the consistent measurement of defined parameters over time can yield critical information for management decision-making. With Medicare and Medicaid audits, investigations, overpayment recoveries and other enforcement activity reaching an all-time high, EMS managers must add a new set of metrics to their tool kit: compliance benchmarking. As with any other type of benchmarking, EMS agencies can monitor critical aspects of billing compliance with specific, measurable performance parameters. The metrics we will discuss below were first presented at the Page, Wolfberg & Wirth Executive
Institute. We call these ―Compliance Performance Indicators,‖ or CPIs for short. Here
are some of the CPIs that your agency can most likely implement immediately within your current software reporting capabilities.
Service mix
 One of the most fundamental aspects of compliance benchmarking is to measure your service mix. This is a CPI that tracks the percentage of ALS, BLS, specialty care transport, emergency and non-emergency calls your agency handles. In recent years, there have been a number of qui tam whistleblower cases and other enforcement actions against all-9-1-1 EMS agencies alleging that they overbilled Medicare for ALS services. These systems deployed paramedics on every call, and then billed substantially all of their calls at the ALS level, believing that the performance of an ALS assessment justified all ALS-level billing.
However, Medicare’s ALS assessment rule first requires that there be a qualifying ALS
-level emergency dispatch (among other things) in order to properly bill for an ALS a
ssessment. In some cases, a full 100% of some agencies’ claims were being billed as ALS emergencies, but Medicare’s own statistics show that the national percentage of
ALS to BLS emergency claims is about 67
33%. So, monitoring your service mix is critical to knowing whether a compliance issue may be lurking in your billing. Other important service mix metrics to benchmark include the percentage of repetitive patient transports, especially dialysis, which are seen as a high compliance-risk area. Also, measu
ring trends in your agency’s performance of discharges from a healthcare facility to a patient’s home could yield helpful compliance metrics, as many audits have
questioned the medical necessity of these types of ambulance transports.
Payer mix
 Likewise, p
ayer mix is equally important to assessing and improving your agency’s
compliance. Payer mix refers to the relative percentages of Medicare, Medicaid,
 
commercially insured and private-pay patients you serve. Knowing your payer mix can help you look at important compliance trends in your agency.
For instance, a high percentage of ―self
-
pay‖ patients may reveal that your agency isn’t
doing an adequate job of capturing insurance information or identifying proper
payment sources for obtaining your agency’s legi
timate reimbursement. A high percentage of write-offs may show that your agency may be improperly waiving copayments or other patient balances in violation of federal law. A percentage of Medicare claims that is out of proportion with the demographics of your service area may show that Medicare is being overbilled for some services.
Overpayment rate
 One standard compliance performance indicator used by Medicare, the Office of the Inspector General (OIG) and other enforcement agencies should likewise be part of
your agency’s compliance benchmarking: overpayment rate (the OIG refers to it as a ―billing error rate,‖ but the term ―overpayment rate‖ is more descriptive). This is
derived by auditing a random sample of claims over a specific time period and calculating the dollar amount o overpayments divided by the total dollar amount of claims paid in the same sample. Overpayments are any funds received in excess of what was properly due and payable. The OIG uses a 5% overpayment rate benchmark to trigger full, statistically valid random sampling in its Corporate Integrity Agreements.
Credit balances & refunds
 Speaking of overpayments, the Federal False Claims Act was amended a few years ago to require healthcare providers to refund any Medicare overpayments within 60 days of being identified, or they become false claims under the Act. This means that all EMS agencies must have an active process in place to identify overpayments and return them to Medicare within 60 days. Therefore, your compliance benchmarking pr
ogram must track ―net days in credit balance,‖ a CPI that monitors the processing of overpayment refunds and the aging of
your credit balance
e.g., at 20 days, 30 days and 40 days. As your credit balances start to creep toward 60 days, you may wander into false claims territory if your Medicare overpayments are not refunded within this federal statutory deadline.
Denied claims ratio
 The denied claims ratio looks at the percentage of denied claims (i.e., the number of completely or partially denied claims divided by the total claims submitted). By tracking this metric over time, you can help identify potential trouble spots in your compliance landscape.

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