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Successful Supervision
Rose B. Moore, CMC, CMOM, CPC, CCP, COMA

The most difficult time for any supervisor is when you have to make the transition from being a worker to being a boss. Your first supervisory assignment brings with it a certain queasiness in the pit of your stomach about supervising people. How will they react to you, and will they challenge your authority? How will you respond when workers do test you?

Q: I've just been made a supervisor in my department. The previous supervisor, who was very popular, just retired. How should I act toward the people I now supervise, after working with them for two years?

A: Be yourself. Don't call attention to the fact that you're now supervising people you formerly worked with. They're just as aware of the problem as you are. In fact, they're trying to figure out how to deal with you in your new role as boss. Keep things running as they were under the former supervisor. Even though you may have some good ideas for improving operations, it's wise to ease into your new job, so that subordinates won't typecast you as a "boat rocker".

Q: What's the best way for a supervisor to earn the respect of subordinates?

A: There's no sure-fire way to do this, since many variables are involved. For example, if you're replacing a boss who didn't get along with the group, it's easy to assume that you'll automatically win favor by comparison. However, it might be that an unsatisfactory experience with a former boss has soured people on supervisors in general. That's neither logical, nor reasonable, but you're dealing with people, and the unexpected and unpredictable are part of the human equation.

If the situation presents itself, one of the most effective ways to gain credibility is to resolve a personnel problem that has been plaguing one of the people within your department. It really doesn't have to be anything significant. For instance, suppose a worker is upset because of an error in accrued vacation time. By taking the initiative to promptly resolve this problem, you're demonstrating an ability to quickly resolve matters that most affect employees - their pay and benefits. This can quickly translate into goodwill.

CAUTION: Whatever the circumstances of your new position, don't attach a sense of urgency to gaining the respect of subordinates. It will come about in time as they get to know you, and recognize that you're both fair and reasonable in your supervisory role.

Program Safeguard Contractors and Recovery Audit Contractors present new challenges for providers
Robert Liles, J.D.

There are some new contractors in town. In addition to Intermediaries (Part A) and Carriers (Part B), CMS contracts with both Program Safeguard Contractors (PSCs) and Recovery Audit Contractors (RACs) to assist CMS with audit and improper claims recovery proceedings.

Program Safeguard Contractors:

The Health Care Portability and Accountability Act (HIPAA) added a new section to the Social Security Act, establishing the Medicare Integrity Program (MIP). The purpose of MIP, in part, was to strengthen CMS' ability to deter fraud and abuse in the Medicare program. As part of the MIP program, PSCs were created. The overall purpose of each PSC is to protect the Medicare Program from fraud and abuse. There are currently twelve PSCs who have been awarded contracts from CMS.

PCS contractors work to enhance CMS' efforts to detect and deter fraud. They provide audit activities in support of carriers and intermediaries. Typical PSC activities include:

• Pre-pay and post-pay medical claims reviews.
• Data analysis.
• Fraud investigations.
• Provider cost report data reviews.
• Provider and beneficiary education.

Working with Carriers and Intermediaries, PSCs often conduct extensive medical necessity and billing reviews of Medicare claims. In recent years, our attorneys have seen a significant increase in cases where CMS and its agents (typically PSCs such as AdvanceMed and TriCenturion) have conducted audits where a "statistically relevant sample" has allegedly been taken in connection with the government's review of Medicare claims.

Disturbingly, in cases we have seen, it is not uncommon for TriCenturion and other PSC's to purportedly find claims error rates of between 85-95 percent. Extrapolating these findings to the universe of claims, they have then sought to recover most, if not all of the funds a provider has been paid by Medicare during the 2-4 year period at issue.

Recovery Audit Contactors (RACs):

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) required CMS to complete a demonstration project to demonstrate the use of RACs in identifying underpayments and overpayments and recouping overpayments under the Medicare program for services for which payment is made under Part A or Part B. In 2005, CMS initiated the RAC demonstration to establish whether RACs could efficiently identify and correct improper payments to providers. The RACs were able to identify several hundred million dollars in alleged overpayments resulting in plans to expand the program nationwide.

Congress authorized the expansion of the RAC program to all states in the recently-passed Tax Relief and Health Care Act. Health care providers should expect to see increases in Medicare audit activity as the RAC demonstration project is systematically expanded nationwide.

From the outset, providers have been concerned that RACs are little more than "bounty hunters" paid a percentage of the amounts they recover. Not surprisingly, CMS disagrees, noting that RACs are also compensated for identifying underpayments, not just overpayments. To date, identified provider overpayments have vastly overshadowed underpayments. As of November 2006, a total of 303.5 million dollars of improper payments had been identified by RACs. In fiscal year 2006, RACs collected approximately $68 million.

I will discuss how to respond if your practice is subjected to an audit at the 2008 PMI Conference for Medical Office Professionals in San Antonio, TX. I'll supply you with answers along with numerous resources and straightforward guidance during my session. I'll also be part of a special panel of compliance experts at the conference. Hear from Bud Paulissen, U.S. Attorney and Chief of Major Crimes Section with the United States Department of Justice Western Division, D.K. Everitt, a compliance officer and Adjunct Lecturer/Preceptor for Trinity University, along with an FBI Special Agent. We'll address your toughest questions in real terms. Visit the conference web site for details on this and many other valuable sessions to be presented at this year's conference.

Ask an Expert

Robert Liles, author of the article above, has joined PMI's "Ask an Expert" Contributing Editorial Board. Each month, Robert will answer selected questions from Link readers and NetworkPMI members. If you have a legal question, you can send it to Robert via our online form, which will be located at network.pmiMD.com later this month. You must be a NetworkPMI member to submit a question. Membership to NetworkPMI is free and includes access to a number of benefits and resources, such as the "Ask an Expert" Panel.

Mr. Liles focuses his practice on fraud defense, internal audits / investigations, compliance and regulatory matters. Mr. Liles has represented a wide variety of clients in civil and criminal proceedings, complex civil litigation, and in connection with reviews conducted under non-profit and Sarbanes-Oxley compliance requirements. Before entering private practice, Mr. Liles served as Deputy Director for Legal Programs at the United States Department of Justice (DOJ), Executive Office for United States Attorneys (EOUSA). Prior to serving in Washington, D.C., he worked as an Assistant United States Attorney in the Southern District of Texas, Houston office, where he primarily handled False Claims Act matters and cases.

The "Ask the Expert" feature will be available later this month on network.pmiMD.com. Watch for Mr. Liles column in future Link Issues to see if your question is selected. Stay tuned as more experts join the panel in the coming months. Experts in collections, HIPAA, compliance, and much more will be answering your questions.

Scholarship Kicks off This Month

Practice Management Institute® is pleased to introduce a new program for medical office professionals seeking to become certified. The J. H. O'Dell Memorial Scholarship Program will award one of PMI's Self Study certification programs and exam each month, beginning in February 2008. Applicants must have at least one year of experience working in a medical office, have a valid email address and access to the Internet to complete the scholarship form located at http://network.pmiMD.com.

Scholarship recipient can choose the Certified Medical Coder or Certified Medical Office Manager packages. The Certified Medical Insurance Specialist (CMIS) is currently under revision but should be available later in the year. Only one Self Study package will be awarded per household. Recipients will be announced on the NetworkPMI Web site each month through December of 2008.

A new scholarship recipient will be selected at random on the last business day of each month in 2008 and contacted by phone. One scholarship form per member please.

FREE Appeals E-Book
By Steven M. Verno | CMMC, CMMB, NREMT-P

Appealing claims is a very complex process and requires a detailed knowledge of several factors to be successful at it. There are many reasons why a claim gets denied and when a provider has spent the time and money on providing a service he/she has that right of being paid for it. Billing staff need to know what to do when appealing those denied claims to get their provider reimbursed correctly for that service.

Now you can learn how to simplify the appeals process and provide additional information for those responsible for this area in the billing office. BC Advantage magazine has just introduced a free tool. The Appeals E-book by Steve Verno, an educator and consultant specializing in medical coding and billing, includes a list of helpful internet links, a breakdown of the Medicare appeals process and contact list for the major insurance carrier's corporate offices. Also included are sample letters that can be used to successfully appeal claims on behalf of providers. The letters included can be used for several possible outcomes when dealing with insurance companies. Readers will also find an example agreement for the patient to allow the provider to act of their behalf.

To receive your free, no obligation copy, click on the BC Advantage graphic and complete the sign-up form.