January 2018 Event in Orange County, CA.

Please continue to my other links on this site if you want to reach me.   Email is jnbloink@hotmail.com    Phone is 970-560-1009

As I was walking my dog along the beach path in San Clemente today… I stopped to watch the surfers. It is truly amazing to me to watch them jump, twist, twirl – in the water- and on a moving surfboard!
As I watched, I thought – this is like compliance! We are always strategizing our moves, learning new regulations and teaching our providers how to swim (stay alive!)
Compliance is an ocean of rules - but we all can learn to surf with lessons and education. For most of us it will be bumpy. And ..ultimately -  the compliance professional is also the lifeguard throwing out a life line of new CPT codes, ICD 10 codes, Modifier Use… as well as trying to translate regulations into understandable and useful information. We will fall and get wet - but it is all about getting back up again! Compliance, Medical Coding and Billing is fun... we just need to watch the waves-

New Healthcare Fraud Community Discussion at ACFE!

Association of Certified Fraud Examiners (ACFE) is starting a Healthcare Fraud Community Discussion Board on Monday October 16th! There will be several topics discussed each week. 
Discussion topic contributions range from both private to government sectors.
Want to learn more? Please join the discussion!
You do not need to be a Certified Fraud Examiner (CFE) to belong to Association of Certified Fraud Examiners (ACFE.) 
This new discussion community might be helpful to Healthcare Attorneys, Healthcare Providers (all settings), Healthcare Plans, Medicare, Medicaid, CHIP, IHS, Beneficiaries, Healthcare Executives, Compliance Professionals, Investigators, FBI, DA Offices, OIG, DOJ, Colleges / Universities, Professional Organizations such as HCCA, AAPC, AHIMA, AMBA, etc. (Sorry if I missed your category!)
Topics will include the What, Where, When, Who and How questions of Healthcare Fraud. The “Why” – Well…I will let you figure that out!
We will also discuss prevention techniques with the use of effective compliance programs. Effective being the key word!
Please share this with your network so others will be informed about this new ACFE Healthcare Fraud Discussion Community! I look forward to reading YOUR thoughts on the many topics that will be discussed!
Jacqueline Nash Bloink
 Co- Leader of the ACFE Healthcare Fraud Community

Anti-Fraud? Also called Effective Compliance!

Healthcare Compliance is the Anti- Fraud "arm" in the healthcare industry. I will present a 4 hour Work Shop (Webinar) for AAPC (6 CEUs) that discusses the PPACA mandate that requires all providers that bill Federal or State payers to have a Compliance Plan in place that includes a Compliance Point of Contact (i.e. Officer.) PPACA made this a "Condition for Participation" with CMS. Although this was mandated in March 2010... it has not yet been "proactively" enforced. Daily we read of providers and healthcare entities that are being fined millions for non-compliance issues (Fraud!) The fines, settlements, CIA's and... imprisonment are currently the "enforcement." An ounce of prevention is worth a pound of fines (or prison time!) But most of all... Healthcare Compliance can save patient lives- as discussed in my August 10 workshop. Compliance is not just about money!
Compliance plans should be unique for every office setting and is not difficult to design - nor expensive. There are many free resources available to medical offices and healthcare providers as well as several training programs in various associations that will assist with training your compliance staff. Please share this information with your contacts if you think this could benefit others!
Hope you can join me in learning more about Healthcare "Anti Fraud" techniques - called Compliance!

The ocean is beautiful if you know how to swim! Effective Compliance Programs are similar to successful swimming lessons. The Coach is the Compliance Officer!

Not only does an effective compliance program lower the risk of fraud in your medical office -the compliance program is required under the PPACA! 
If your medical office bills Medicare Advantage Plans (Part C) – you probably have to attest every year to the Part C plan that you have a compliance program. A program that includes training, compliance point of contact, audits, policies and procedures, etc. (7 basic elements.)
I will walk you through the steps during the August 10th American Academy of Professional Coders (AAPC) webinar where we discuss what medical offices / professionals- must do to design a compliance program to be compliant. Compliance might be a new career for those that have a passion for compliance – we will discuss this as well.
Compliance helps to protect the money that is earned legally and ethically by the providers of your medical office – Let’s help to make all medical offices compliant! Please share with your connections if they might be in need of this information!
Please go to the AAPC Webinar website if you are interested. 6 CEUsPrice is reduced to $99.95 for members if purchased by July 31st (use discount code PPACA.)
* And Yes.... My dog loves the ocean!
Jacqueline Bloink, MBA, RHIA, CHC, CFE, CPC-I, CPC, CMRS

Anti Fraud Tips Regarding the TCM CPT Codes _June 2017

2017 OIG Work Plan Red Flag:    Transition of Care Management (TCM) CPT Codes
TCM was designed to assist the patient with the transition from an inpatient setting back to the home or another outpatient setting. The goal of reconciliation of medications, outpatient therapy, community services or other healthcare services- will assist the patient from being readmitted.
Benefit to Patient: Assist with reduced inpatient admissions.
Benefit to provider: This is a great - high revenue CPT code. Medicare reimbursement ranges from $190 – 280.00 (better paying than most established patient CPT codes.)
Risks: Follow the rules set forth in the Federal Register and CMS Fact Sheet. Educate your staff on what needs to be performed and documented prior to seeing the patient as well what needs to occur during the patient visit and during the following 29 days. The patient and provider both win when there is compliance with TCM rules and lose when required steps of the TCM codes are eliminated.
OIG 2017 Work Plan, Page 32
We will determine whether payments for TCM services were in accordance with Medicare requirements.”
CMS December 2016 TCM Fact Sheet:
AAFP TCM Services (J. Bloink and K. Adler) 2013:
Please contact me if you have other questions.
Jacqueline Bloink, MBA, RHIA, CFE, CHC, CPC-I, CPC, CMRS
What gaps are in your RAF????

DOJ:  Tue May 2, 2017:     United States intervenes in FCA against a Medicare Advantage Plan for mischarging the Medicare Advantage and Prescription Drug Program.

What the heck does that mean?  It means (in Medical Coding Language) that the diagnosis code (ICD 9 or ICD 10) used for the beneficiary- enrolled in that Part C Program might not have been documented / found in the provider chart note for the time frame required by CMS. Or… That the beneficiary did not have that condition / diagnosis at all.  Or… That the Plan perhaps added diagnosis codes that did not pertain to that patient (s.) Various scenarios.

Why does that matter? There are about 9,000 ICD- 10 diagnosis codes (out of a total of 68,000 ICD- 10 codes) that have a weight assigned to them by CMS.  These 9,000 codes are grouped into Hierarchical Condition Categories (HCC).   Each diagnosis code in these HCC groups have a weight assigned to them based on the severity of the diagnosis (just how sick the patient really is.)  For example, a HCC weight for Secondary Malignant Neoplasm of Right Lung has a weight of 2.484, whereas Primary Hyperparathyroidism has a weight of .245.  The weights of these HCC diagnosis codes are added up for each patient during January 1 through December 31 each year (resetting on January 1st again for the next year.) This cumulative weight or score of these HCC diagnosis codes are referred to as the Risk Adjustment Factor (RAF.) The higher the score usually means that the patient is very sick with many complications, thus the Medicare Advantage Plan (Part C) receives more money from CMS in subsequent years to take care of the beneficiary in that geographic area.  There is also a weight assigned for the patient age, gender, disability status, geographic area and living quarter status / institutionalization status.

We will start to see other FCA cases such as this going forward because there is a lot of money that is given each year to the Medicare Advantage Plans across the United States.

I hope this was simple so that everyone could grasp the broader concept. This case can be found at the DOJ website: https://www.justice.gov/opa/pr/united-states-intervenes-false-claims-act-lawsuit-against-unitedhealth-group-inc-mischarging  

Jacqueline Nash Bloink, MBA, RHIA, CHC, CFE, CPC-I, CPC, CMRS
Healthcare Compliance and Fraud Specialist

How Effective is Your Compliance Program?

Just released today (March 27, 2017) by the OIG is a resource tool: Measuring Compliance Program Effectiveness: A Resource Guide.

Jacqueline Nash Bloink, March 27, 2017