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Zeroing in on Physician Coding & Documentation Risks: Using Data to Improve Your Auditing & Monitoring Program

Cheryl T. Batich, Manager, PricewaterhouseCoopers LLP

Chandra Stephenson, Senior Associate, Consultant, PricewaterhouseCoopers LLP

  • The benefits of using benchmarking and data analytics to strategically focus your auditing & monitoring efforts
  • Tools and best practices for customizing your audit approach based on outliers and known high-risk compliance issues for your practice/specialties
  • Incorporating charge capture, documentation, coding, and billing process reviews into your auditing program to facilitate root-cause analysis and to identify effective methods for remediation

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Identifying Compliance Problems Within Your Practice

Cristine M. Miller, Partner, Mountjoy Chilton Medley LLP

  • Use of data analytics and OIG targets to identify potential issues
  • Utilization of coding audits to maintain compliance integrity
  • Prevent compliance problems through ongoing provider training

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Compliance Risks in the EMR

Sandra K. Giangreco, Coding Compliance Audit Senior Manager, CHAN Healthcare

Kimberly G. Huey, President, KGG Coding & Reimbursement Consulting

  • The Documentation Guidelines for physicians were written over twenty years ago, before the widespread use of electronic records; CMS has not updated these guidelines, but in some cases, Medicare Administrative Contractors have
  • Compliance risks and common mistakes found in physician documentation in electronic records; a review of each type of service and tips for documenting appropriately in an electronic record
  • The findings of governmental and payer audits that found fraud and abuse in the use of electronic records; learning from these cases to protect your organization

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Clinical Workflow Change In Response to New Regulations: A Case Study

Dale Shultz, Director - Regional Compliance, Baylor Scott and White Health

  • How to identify both indispensable parties — and necessary parties — as quickly as possible in the process and to obtain their buy-in for change in workflows directly impacted by new or amended regulations
  • How to determine equitable accountabilities, provide guidance and assistance throughout the planning and implementation, then hold all parties to the timely achievement of all deliverables
  • How to create a groundswell of support for necessary clinical workflow change

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Compliance for Teaching Physicians: What Have We Learned?

C.J. Wolf, Faculty, BYU-Idaho; Senior Compliance Executive, Healthicity

Jay McVean, Director, UT Health

  • PATH (Physicians at Teaching Hospitals) audits were among the first major compliance enforcement initiatives in healthcare; why this is still a significant compliance issue
  • How compliance professionals at one teaching institution provide training, audits, and tools for teaching physicians
  • The key attestation statements and documentation processes to follow in order to stay compliant

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OIG Update: Key Priorities in Compliance

Ruth Ann Dorrill, Regional Inspector General, Office of Evaluation and Inspections, Office of Inspector General, U.S. Department of Health and Human Services

  • OIG’s work plan and top HHS management challenges
  • Use of data analytics in program evaluation and compliance
  • Guide to new OIG compliance resources

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Patients Over Paperwork: Updates from the Centers for Medicare and Medicaid Services

Jean Moody-Williams, Deputy Director of the Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services

  • The efforts underway at CMS to ensure that they put “Patients over Paperwork” as they decrease the hours and dollars clinicians and providers spend on CMS-mandated compliance
  • How the Meaningful Measures Framework will be used to reduce burden and to ensure availability of high-impact measure areas that safeguard public health, are patient-centered and meaningful to patients, and are outcome-based where possible
  • new areas that CMS should consider to ensure that clinicians and providers have more time to spend with their patients

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Measuring Compliance Program Effectiveness

Debra Troklus, Senior Managing Director, Ankura Consulting Group

  • Understanding the OIG Compliance Effectiveness Resource Guide
  • What elements to measure to determine program effectiveness
  • How to measure each of the seven elements

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Provider Compliance Obligations Under Medicare Advantage and Medicaid Managed Care Plans

Anthony Choe, Counsel, Polsinelli PC

Ryan T. Lipinski, Director Government Programs Compliance, Blue Cross and Blue Shield of Illinois

  • Why and how payors are ramping up their compliance requests for providers, including a review of statutory, regulatory, and contractual requirements
  • Key obligations that arise from emerging payor–provider relationships and reimbursement models
  • How to monitor — and ensure compliance requirements are being met — for multiple payors; what to do when issues arise

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HCCS: Guarding Against Upcoding Practices

Rose Dunn, Chief Operating Officer, First Class Solutions, Inc

  • HCCs are a reimbursement methodology used by Medicare and third-party payers to determine a provider’s reimbursement
  • HCCs are Medicare’s way to reimburse Medicare Advantage health plans to accept complex patients; but do those plans share the reimbursement with the providers?
  • HCCs are driven by diagnosis coding; do you have a way to protect against upcoding practices?

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Physician Practice Compliance: From A to ACO!

Joseph A. Piccolo, VP of Corporate Compliance, Inspira Health Network

Karyn B. Holley Director of Corporate Compliance, Inspira Health Network

  • Building an infrastructure for the evolving nature of physician relationships
  • Developing an education program that meets the needs of both employed and non-employed physicians
  • Establishing collaborative and effective strategies for physician engagement

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HIPAA and the Medical Practice: Requirements for Privacy, Security, and Breach Notification

Gina L. Campanella, Partner, Gallagher Campanella LLC

  • The basic requirements of HIPAA and how to apply them meaningfully to your practice
  • An overview of recurring HIPAA obligations and updates required by passage of the Omnibus Rule in 2013
  • Preparing for a federal government HIPAA Audit and the increased trend for surprise audits

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Monetizing Quality: How to Align Quality with Compensation Models and Payer Contracts

Jon Burroughs, President and CEO, The Burroughs Consulting Network, Inc

  • How to calculate the monetary value of quality metrics in an increasingly pay-for-value era
  • How to align executive, physician, and practitioner compensation with monetized quality metrics and payer contracts
  • How to work with payers to create pay for value contracts that benefit your organization, the payer, and optimizes quality care

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Developing a Compliant and Effective Ambulatory Clinical Documentation Improvement Program (ACDI)

Ellis Knight, Senior VP/CMO, Coker Group

  • The major differences between inpatient and ambulatory CDI programs
  • The ways in which hierarchical clinical conditions (HCCs) must be addressed in the medical record for them to be used for risk adjustment purposes
  • Why ambulatory CDI will be of vital importance as value-based reimbursements (e.g. MACRA) become more the norm in the industry

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Not “For Your Eyes Only”: How an Independent Audit Boosts Compliance

Jeanmarie Loria, Managing Director, Advizehealth

  • How a third-party audit can benefit medical facilities of all kinds through education, objective opinions, physician engagement without consequence, and more
  • How to select audit, ID scope, and apply findings to adjust your practice’s compliance plan
  • A case study that reveals the efficacy of audits and its relationship to creating a culture of compliance in clinical practices of all sizes

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Incident-To: The Convergence of Access, Documentation, and the Bottom Line

Lynn M. Myers, VP of Quality, Texas Health Physicians Group

  • The differentiation between incident-to and split shared billing
  • Ways to mitigate against billing errors
  • The importance of education of staff and providers
  • The distinction of incident-to between commercial and government payers

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Opioid Crisis: How to Monitor for Compliance

Miriam B. Murray, Compliance and Privacy Officer, Physicians Group Services

Peiman Saadat, VP of Regulatory Compliance, Corporate Compliance Officer, AdvantageCare Physicians

  • Current status of the opioid crisis nationwide; organizational risks and impact
  • Local coverage determination (LCD) for Controlled Substance Monitoring
  • What the PDMP tells you
  • Auditing and monitoring medical necessity documentation; monitoring your providers’ prescription pattern
  • Collaboration with prescribers to mitigate risk
  • Compliance Officer role: a success story

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Patient & Employee Record Retention Strategies When Systems Get Replaced

Shannon Larkin, VP Marketing & Business Development, Harmony Healthcare IT

  • Potential patient and employee data exposures when an EMR or ERP system is replaced; the impact of disparate silos of data on your record retention policy; industry trends and best practice for legacy data management
  • A variety of options for handling and securing legacy data long-term, with a cost/benefit analysis — as well as pros and cons — for each
  • The cybersecurity of patient & employee data stored in legacy EMR & ERP systems; security vulnerabilities from applications & technologies that are potential targets for hackers; how to avoid data breach & decreaser

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Data Matters: Are You a Target for an E/M Audit

Angie M. Babb, Consultant, Blue and Company

  • What your data may be saying; the best defense is to be in the know
  • Will your documentation and billing practices support your data?
  • Minimize your risk of exposure; be in the know

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Exit Transitions When Provider or Clinics Leave Your Organization: What Compliance and Medical Records Concerns to Consider

Valerie T. Cloud, Interim VP and Regional Corporate Responsibility Officer, Catholic Health Initiatives

Lori L. Richter, Director, CRP EHR OneCare Compliance, Catholic Health Initiatives

  • The risk associated with medical record transition when providers and clinic exit your organization
  • The importance and relevance of having written policies and procedures
  • How the data transfer will occur to protect authenticity of the medical records

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Physician Practice Enforcement Actions: Could You Be Next Year’s News?

Glena Jarboe, Compliance Manager, University of Kentucky

Sarah M. Couture, Senior Associate, Ankura Consulting Group

  • A twelve-month summary of published enforcement actions against providers and physician practices
  • A simplified approach to a risk assessment for your practice, large or small
  • A practical compliance plan based on your risk assessment

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Best Practices in Controlled Substance Prescribing and Documentation

Denise A. Dach, Corporate VP of Compliance, McLaren Health Care

Michelle l. Pinter, Corporate Director of Medical Group Compliance, McLaren Health Care

  • Basic guidelines for safe prescribing of controlled substances — patient agreements, state prescription drug monitoring systems, lab-based compliance monitoring, documentation requirements, and managing prescriptions and refills
  • Handling non-compliance with controlled substances — identifying red flags, provider/pharmacy shopping, patient behaviors, abnormal drug screens, crucial patient conversations and documentation, terminating provider–patient relationship for non-compliance
  • Recommendations on handling medical marijuana

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Managing Conflicts of Interests at Your Organization

Jennifer R. Bottoms, Conflict of Interest Program Manager, Corporate Compliance, Novant Health, Inc

  • Key components of a conflict of interest policy
  • Leadership buy-in for your conflict of interest program
  • How managing conflicts of interest mitigates organizational risk

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