Elevate Your Referring and Ordering Physician Monitoring

Hello. Hello, friends. Happy Thursday afternoon or morning, depending on where you’re joining us from. We’re thrilled to see all of you. I’m watching y’all join on at the moment. Thanks for being early for those folks that are here. Do me a favor if you can while we’re just while we’re giving it a minute or two to get rolling. Give me a minute or two or, if if you if you can hear me and you can see my screen, just drop a note in the chat real fast. That’d be super helpful. And just say, Dave, I can hear you. That would be awesome. Here we go. Getting a few in. Working fine. Thank you, Lisa. Thank you, Barb. Thank you, Jason. There is Donna, and then we’re, letting Michael Rosen join on as well, and we will get rolling. Alright, friends. We got a good session today, that I’m really, really excited for. So I’ll kick us off, and then I’m I’m I’m gonna throw the mic over to Mike and Donna as well. I’ll introduce them both. If this is your first webinar or whether it’s your thirtieth webinar with ProviderTrust, we are thrilled you’re here. Thanks for spending some time with us. And we have a really a really interesting topic and really relevant one based on what you’ll hear from today and what we’re seeing, just coming out from the OIG as well. So a couple of housekeeping things before we get rolling. We do our webinars on Zoom, and that’s really intentional. So if you have a question or you’re you’re looking to get something answered from our team, go ahead and drop it in the chat, and we’ll get we’ll, certainly save some time for questions at the end if any come in. And if not, we’ll get them routed to the appropriate person at ProviderTrust. So, please feel free to ask questions and keep this, just if we can help and max the value for you, go ahead and ask us questions. You will get a copy of the slides and this is being recorded. So if you are here today, you’ll get the recording and the slides later this afternoon. This is also good for CEUs, so you will get that detail from our team as well, either today or tomorrow as soon as we, get out all the materials. So anything else, just let us know if we can help in any other way. And with that, let’s get rolling. Today’s topic, elevate your referring and ordering physician monitoring. This has been big in our organization and something we are spending a lot of time, a lot of energy, and and just just a a lot of, a lot of partnership energy with each of you and so many of you figuring out what’s happening and how can we how can we solve such a growing and emerging trend and problem that we see in the industry. If you don’t know these two folks, you are you are in some pretty fine company today, friends. Donna is our chief compliance officer at ProviderTrust, with over twenty five years of experience in the compliance domain as a chief compliance officer, is truly a subject matter expert, has a background in post acute, but has even, has really elevated into the payer world, into the acute world as well over the last, over the over the last stretch of her career too. So just truly is incredibly well known and respected in the industry. We’re We’re thrilled that she continues to to present with us on these webinars. And then Mike Rosen as well as a cofounder as a background as he would describe as a recovering attorney, but certainly serves as our our subject matter expert on following the OIG and enforcement trends. It continues as well to be a subject matter expert and speaker, very active, in the compliance community across the health care ecosystem. So Mike and Donna, thanks for joining us. I’ve got two more slides. I’m gonna kick the mic to y’all. Little bit about provider trust. If you don’t know who we are or what we do, I think it’s important to tee up where we live in the world that helps us, helps us, best understand the trends that we can best present to you what’s going on, what’s happening, and how do how do we recommend you solve that problem. So provider trust, we’ve been around for over a decade now. Our anniversary party is actually later tonight, our twelve year anniversary party. So we’ve been we’re it’s our it’s our birthday. We’re focused solely in health care serving across the ecosystem. We now monitor more than six million providers, individuals, and entities on an ongoing daily continuous basis. We use automated compliance intelligence to enrich primary source data. It’s a big part of where what we do, and we we’re pride we’re prideful of of, setting a security and a quality standard across what we do, which is ongoing compliance monitoring. And all of that, you know, we’re proud to be recognized as the best place to work, but we live in this the world of ongoing compliance monitoring, taking primary source data and screening your populations what we’re all about. And so today, here’s what we’re gonna cover around this specific topic and this specific agenda. We’re gonna start with what does the OIG say around referring and ordering physicians and compliance. What what let’s start with let’s start with the regulation. Right? What is what is the OIG say? Let’s actually talk a little bit about the nuance of the population, referring, ordering, and prescribing. How big is this risk? When when when we are talking about this population, what are we talking about? We’re gonna actually use a case study of a very recent, very relevant if you follow our executive brief series either on our website or on our social media, you’ll notice we’ve written about, a case, Suma Health, which we’ll cover today. What can you do? What’s best practices? And certainly q and a as we go. So with that, I will kick it, Mike and Donna, over to you. And if you have any questions, friends, just as one more just to say one more time, just drop them in the chat, and we’ll get them routed or asked live here on the phone. Thanks, Dave. Welcome, everybody. It’s, kinda sad. Dave, Mike, and I are all in the office together for the first time in in a while, and yet we’re in three little different call rooms because we decided it it would be easier for all of you. But, we are excited to be together, and we’re excited for you all to be with us today. So, like Dave said, let’s just start with the OIG. He was so kind in in his words in introducing Mike and I, but really when it boils down, right, we care about what the office inspector general says and what they, guide us. So we thought that’s where we would start. So these are just three quotes out of the OIG special advisory bulletin. I know we’ve talked about that, document many times. But if you haven’t read it recently, it is always great to, use it as a refresher when we’re talking about exclusion monitoring and expectations from the OIG. So as it relates to, this really kinda unique and difficult population, I pulled just a couple of quotes, out of the advisory bulletin. And the first one, right, is the one that we focus on all the time. We all know that, no federal monies can be, paid based on services, or items that were furnished by an excluded person. And I highlighted number two. Right? Or at the medical direction or on the prescription of an excluded person. So, again, down to the basics. The second one is some guidance that they give that the OIG gives us as excluded. Now all of us that have excluded. Now all of us that have lived and worked in this environment are like, oh my goodness. Do they not understand how difficult of a task it is? Which we all do recognize that. So we’re talk about that a little bit at the end, but I think good, again, to see their recommendation. And the third piece is just is just speaking into, what our civil money penalty, you know, what that liability might look like. And, again, is it it’s explicitly reminding us that it’s not only for those, employed practitioners or those employed people or the the true vendors that we work with, but also as it relates again to that same medical direction or prescription of an excluded person. So that’s kind of the the level set. That’s where we wanna start. And now Mike is gonna take us through some examples and some really start talking about what that that claims volume looks like, those dollars and the risks that are in play. So, Dave, if you don’t mind moving us forward, Mike’s gonna jump in. Thanks, Donna. Happy summer to everyone. If it’s anywhere like Tennessee, it’s blazing hot too early. But, we’re glad you joined us today. What we thought we would do is paint a picture of your world. And as we see it, the various different points of entry in which different, suppliers, providers, employees, vendors, pharmacists, networks, credential providers, all touch and help you touch your your, services and help you provide the care that you do. We’re only gonna focus on two of them today. That’s the second bullet point of ordering or prescribing physicians and referring. I think a lot of people are, surprised that referring physicians are covered under this, and we wanna explain to you why that is. And we’re not gonna address any of the other components at the bottom. We’ve got plenty of webinars and ebooks and other things to help you if you would like to know more about that. But today is just on two of those components. And also recognizing that we know that this is and Don’s gonna cover this in a few minutes, how hard it is to either capture or even culminate all this information in a way that you can, comfortably know that you are covering this risk. Why? Because this data resides in multiple places. It could be in an EMR. It could be in a claims management system. It could be in your privilege and credentialing or even your payroll where you might have to get of course, your billing, could be in multiple components or parts within an organization. So we realize that what we’re about to address seems very easy, to explain, and yet gathering the data, or the entry points is is probably not, but we’re gonna give you some best practices to to make that, more reliable. So on the next slide, we, taken a, a we’re what we are what we consider ourselves are very good about understanding where data comes from, how to analyze that data, and for our world, how to even supplement it by making and augment it by making it better. In this case, what we did was we took a nine month slice of a very large health system, which will remain unnamed, and looked at their outpatient claims data publicly available or, in your case, available through collection of all of your Medicare billing, information. And in a nine month period of time between January and September of about We’re only talking Medicare. We’re not talking Medicaid. We’re not talking about private insurance or employer paid insurance, Blue Cross, or others. This is simply Medicare, and it’s a very large health system because we thought that it would give you an idea in scope to what it might mean to you in a smaller organization. In particular, during this nine month period of time, there were almost exactly forty thousand unique providers that provided care through this health system and provided a Medicare service of right under forty thousand. Thirty nine thousand eight hundred and ninety four unique providers. The billings that went as a result, and this is public record information, was five and a half billion dollars. This is not even a full year, and it’s not including Medicaid or other pay. So this is a large system submitting claims, of course, not getting paid that full amount. But but, if if under the, billings they could, this would be the the outlay from, Medicare. When we looked at those providers, we took, a a a special slice into and looked at all of those almost forty thousand providers. Because it included an NPI number, we were able to determine if they were excluded, if they had opted out, and if they were excluded at a state or federal level. And that’s what we do at ProviderTrust, so you would expect that we might be able to do this with just that limited information. We did not have Social Security numbers. We do not work for this this health system. This was just simply looking at data and checking what could be known through the way we do our data analysis. We did find three hundred and forty five providers within the thirty nine thousand eight hundred and ninety four unique providers that were flagged, flagged for either an opt out or an exclusion at the federal or state level. I know that number surprises you. We don’t know how to benchmark that compared to others, but, obviously, if you’re smaller than a forty thousand unique provider operation, your number should be smaller, but, still, this is a pretty significant number. So taking a look down that, food chain, of those three hundred and forty five flag providers, we found forty three of them were either inactive or had an inactive license and or were excluded at a federal or state level. That’s a problem. As we all know, this creates a, OIG issue and would would, require a self disclosure. It also there were three hundred and two, one percent of this population, had had opted out of Medicare. They had registered with Medicare that they do not want to be paid or provide services under Medicare, and yet these are claims that were submitted by those providers. And so you have three hundred and two, totaling four and a half million dollars of Medicare charges that somebody’s gonna have to pay back because these providers went on a public record website and decided they didn’t wanna receive billings for those care. So these are two, an example of two datasets among many that you would wanna know somewhere in your in your ecosystem. And you can see we blurred out the names of these attending physicians, but with an NPI being provided, we were able to back into whether or not those NPIs had opted out or were involved in an exclusion at the state or federal level. Forget the billings to the side. We’re gonna talk a little bit more. I thought it was important to show you the specialties. They ranged from surgery to hospitalist to family practice, all over the place. So there’s multiple places in which, this this hospital system has has some exposure. So on the next slide, we’re gonna get a little bit deeper dive. Again, in context, this is only ordering, referring, attending, and prescribing. This is not, Medicaid. This is not private pay or insurance reimbursed. These are for Medicare for this population. Of that population that we just drilled down to, there were eighteen excluded providers representing fourteen different specialties. We talked about some of those family care. There were some orthopods. There were hospitalists, etcetera. Of those eighteen excluded providers, three, we’re gonna show you, are on the OIG list. So there’s three self disclosures, that that you would need to be making in order to avoid the the trouble damages on top of the penalties. And two, SAM. So of the federal datasets, there were five of those, records included in the eighteen providers individual providers who were excluded. Yet with eighteen individual providers, there were twenty state Medicaid exclusions, and you’re gonna see in a moment that some of these providers were excluded by multiple states. And we don’t know where this hospital, provider provided service. Maybe they weren’t, although excluded by Ohio providing service in Ohio, yet something that you would wanna know, to make sure that you’re not providing service in that area. One of those eighteen excluded remember, there are three hundred and two opted out providers, but one of the excluded providers had also opted out. So multiple flags on this individual. And the total Medicare charges of the five billion for these simp, just these eighteen excluded and, providers is three point three million dollars. And we don’t have time to get into how the OIG would fine or or provide a civil monetary penalty. But as you know, it’s gonna be, either this number, which are also considered possible false claims, you shouldn’t have submitted them, that go back plus some, damages, trouble, or otherwise. Okay. So now that we kinda understand bringing down from forty thousand, if you’ll go to the next slide, to the three hundred and two opted out and, those who were excluded, let’s take a look at some of the ones that were, I guess, the most egregious, if you will. We did that based on, looking at their specialty and, Medicare, charges. Right? And so you see million dollars of submitted charges. Now, sadly enough, that hospital system only got paid eighty eight thousand for that. But the submission of a claim, according to the special advisory bulletin, is all it takes to get you in front of the OIG. If they don’t pay you or they don’t pay you all of it, it’s not what they pay you always. It’s the SPAC that you have submitted. And so you see in these cases, if I if you remember, some of these, these are the three OIGs, but several of these are also excluded in multiple states. And so the problem is exponential even of eighteen providers among forty thousand that we narrowed and drilled down to. And, again, it was about three and a half three point three million dollars in charges that are at stake at for reimbursement and fines and penalties. So this is a little bit of a deep dive. We don’t have time to get in more of it, but, hopefully, you can take that, extrapolate what that might mean as a percentage for your organization, even if smaller, to what exposure potentially is out there. Next slide, Donna. Let’s talk about a case in which the OIG did go after for multiple reasons, this this area of ordering, prescribing, and referring. Thanks, Mike. So this is a twenty twenty two, OIG settlement, that I thought really kind of pulled everything together and also has, some of these ordering providers. But I think, this case was just very unique one that we don’t see often where it had, it involved a payer and a provider, an employee, and an ordering, three ordering, practitioners. It involved a state Medicaid exclusion. Mike just showed you on that last slide. Right? There were, a number of folks that were excluded by the OIG, by Sam, and then a variety of states. And then so the specifics of this case and and Dave mentioned, I think we have an executive briefing. We might even have a blog specifically on this one with some additional information. But the allegation and Summa Health self disclosed this information. So right off the bat, right, the OIG says, good job. Thanks for self disclosing. Well, you know, the penalty will only be one and a half times versus trouble damages. So, that was kinda that first first piece of information. But in the the next bullet, right, it employed an individual that was state excluded on the Ohio state exclusion and excluded also from by the OIG, right, a federal health care program. And the allegation is that Summa billed Medicaid, through its Medicare its own Medicare Advantage Plan, which was called SummaCare, for DME services ordered by three physicians who were excluded. And just by the way, right, we’re not on the medical staff, Right? Which implies, from the way it was written. But I think it’s really important here. Right? They’ve identified all the different exclusions. This company, as we’re seeing a lot in our health systems today, right, we have a lot of companies that are payers and providers. Right? They have their own, Medicare Advantage Plan or their Medicaid Advantage Plan. So our health systems are getting more and more and more complicated. And as we are trying to manage what those different business relationships are to make sure that we’re staying compliant just in the relationship side, now we have these other, third parties that are ordering and prescribing that that fall into this. So as we know as compliance professionals, right, nothing gets easier. It just gets more complicated by the day. And I think this is a great case of kind of the real world of what many of our health systems are are dealing with and what you all are dealing with as compliance professionals. So it’s a case that, you know, the the OIG, it’s on their website. You can go out, take a peek at it, and do a little of your own research, or you can just take this slide and use it when you have to go back into your own organization and say, this is why I need more help. Right? Because we’re trying to manage the complexity that’s, that that’s put forth right here in this one settlement. So let’s talk about in the next slide. So what? What can we do? How can we help you? I think about when I sat in your shoes and and was the chief compliance officer. One of the challenges for me always was, you know, how do I figure this out? Right? I don’t have all the data. I don’t have the authority to just go grab this piece or that piece of information. I have to sit down and and really talk to other departments and think about where can I find this information? So when I think about specifically for this population, there’s kinda two places that I would look. And the one we put here is really kinda starting with billing, but you also have your EMR. Most likely, your EMR has some set of data that relates to practitioners and would have an NPI in there. Any of our, referring, ordering, prescribing practitioners are probably in your EMR. My experience with an EMR is that we don’t oftentimes, maintain that data very well. So I might have a practitioner that’s in my EMR that hasn’t actually, you know, touched a patient or prescribed anything for three or four years. So that’s it might be a TSH out of date. As opposed to your billing system, you probably have a claims date, right, in that billing system that you can use as a filter to make sure that I’m really looking at the population of practitioners that are engaging and generating, monies, in the current day or maybe in the last six months or whatever time frame that you would wanna look at. So both both places good places to start. Billing data might be a little bit allow you to narrow down the populations a little bit better. So within that, then I would be sitting down asking my, team, so what? So what kind of pieces of data are in my dataset that I can figure out who are nonemployed practitioners or noncontracted where we’re not paying them a stipend, where they’re really just those, you know, referring and prescribing or ordering. And then how easy is it to get data out? Right? We might have it all in the system, but maybe maybe I don’t have the ability to get it out. So really working with that team saying, okay. If I could whittle whittle down what I really need, I really need a name, and I really need an NPI number. And, if you could give me a city and a state or some other piece of information, that’d be great. But can you at least give me these two pieces of information? And then, you know, Mike showed you a couple of those slides that just had some basic billing data. Right? So can I do that? Can I pull anyone that’s in these two categories in twenty twenty two and get a dataset that says, gosh? For those, you know, those practitioners, we build a million dollars or we build, five hundred thousand dollars. That’s the information in my in my world that I would use with my leadership team to go back and say, and, therefore, I need some help. I need to start monitoring these folks. I haven’t monitored them in the past because we just didn’t have the ability to get the information. But here’s our risk. Right? Here’s the data that shows me the claims. Maybe it’s the number of claims. Maybe it’s the dollars. Maybe it’s the number of of practitioners. Look at the data and tell your own story. And I think that’s the piece that as a you know, sitting in in my shoe here today, but having sat in your shoes, like, I think that’s where I would start. And just trying to paint that picture and and tell a story to the people within the organization to help really, identify the risks. I might take the very first slide that we had. Here’s what the OIG says. Here’s what my population looks like in our world. Therefore, our our, you know, kind of our our bucket of risk is right here, and then have a thoughtful conversation about so what. What are the resources I might need to do that? What what’s an easy way to get started? So that was a a quick overview kind of of this population and some risk, and I think Dave is going to, wrap us up. I was on mute. So I I I think the last piece to this story, and then we we did, we at least got one, one or two questions come in that I think we’ve got some time for. Is the last piece of this story is, a critical one around data is, so many folks on the phone are at least either directly working compliance or at least work very closely with compliance, has been that’s typically what our audience is when we do presentations like this. And this is a really interesting one because when we talk about compliance, there’s always the question of, well, how much data do you have on this population? If you know anything about provider trust, you know, a lot of a lot of where our business started was ongoing compliance monitoring for employed populations. And for employees, when you think about the data that an organization has on their employees, it’s remarkably consistent from company to company. It may look, it may be formatted a little bit differently, but by and large, everyone has a name, on every employee. Everybody has a Social Security number. Everybody has at least one address on file. Everybody has at least the date of birth on file, and the the data fields become a pretty consistent game to manage through. So much of what we see in our world is when you starting when you start to get into ordering, referring, prescribing, and attending physicians, And, by the way, the difference is I don’t wanna overstate the differences between each of those four as well. The workflows and how you manage an order an order that’s coming in versus an attending are very different and often touch different departments and, different processes to even collect that data to then appropriately monitor it. So I hope you don’t hear us brushing over the nuance that actually goes into ordering, referring, prescribing, and attending because those are very different types of physicians that interact within your organization. Something that might be a common thread in between all four, though, is just how much data do you have on each of those physicians. And something that we have heard for years now from compliance professionals is for my ordering and referring physicians, all I have is an NPI. I can’t consistently rely on name. I can’t consistently rely on, certainly, not a date of birth or an address. Almost definitely, do I not have a Social Security number for an order of referring physician? That’s not that’s not common at all. And so so much of what we do at ProviderTrust is to say, okay. Like, how can we approach this problem a little differently, a little a little uniquely? So if you haven’t heard a little bit about this, our our sort of our latest innovation from a product standpoint is to actually connect to one singular NPI number. How do we go across the health care ecosystem and pull in license information, pull in date of birth and address, pull in Social Security number in some cases to give you a full picture of compliance with one unique identifier. So so much of we do at Provider trust is to say, okay. If all you have is an NPI number in your EMR, that’s actually all we need to give you an instant, accurate, guaranteed exact match result to say this person is definitely compliant, or this person’s excluded, or this person is opted out based on our data enrichment process on the back end. So if that can be helpful in any workflow, certainly, that’s a lot of the work that we’ve done. We’ve I even see some folks on the phone that we’ve done this for and with. So certainly grateful for the partnership from those. But if it if that’s helpful as you consider, the ordering, referring, prescribing, and attending physician populations, just I think we’d just like you to know that we we we’ve been working on this for quite some time because it’s a really interesting nuanced compliance problem to solve that we can now solve. And the last thing I’ll say is as we move to wrap up here, we did have one question come in, which is, around, who does compliance typically work with on this process? So much of what y’all hear us talk about historically is connecting HR and compliance. And almost always, we’re when we say connecting HR and compliance, so much of our webinars have been about the employed population. This is a little different, right, when we’re talking about physicians and where do those live within the organization. And so, if we were gonna replace HR with something, you know, Donna and Mike, from your experience in working with so many of our clients. Right? What what if, who are the counterparts our compliance friend should go to when we need to think about the full picture of how to address a problem like this? Yeah. Absolutely. It’s it’s it’s really, you know, your billing team, your chief medical officer. It’s it’s the folks that are are engaging with those practitioners or where the data is gonna live. Right? And some of it may very well be, you know, someone in the IT team. Right? Depending on the sophistication of the organization and and the number of systems that we might have. We have to find the data. I mean, first first off, you gotta figure out where they live. So having conversations with with billing and with, again, the chief medical officer and any anywhere that those people are kinda coming into our organization and under and just peeling back the onion and asking the questions. Helpful. Friends, it’s twelve thirty, and I think in the spirit of of committing to to ending on time, we’re gonna go ahead and wrap up. You will get the recording. You will get the slides. If you’ve got any questions for us that we can help answer that we just didn’t get a chance to today, given that it was a short and sweet session, please feel free to reach out. We’ll get them answered. And if we can help you in any way, start to at least frame up how to approach compliance monitoring for the referring, ordering, prescribing, attending physician populations. That is something we do quite well and we’re pretty familiar with. So if there’s a world in which we can help you, we’d love to. Friends, that is it. Have a wonderful rest of your Thursday, and we will see you soon on the next provider trust webinar. Take care, friends.