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  • Michael Breslin

The Costs of Non-Compliance

Updated: Oct 30

Medicare, Medicaid, and Commercial Payor audits, unfortunately, are here to stay. According to the 2017 CERT report, CMS paid $390 billion in claims and paid $39 billion in error. Out of the $39 billion dollars;

· 64.1% were due to insufficient medical documentation

· 17.5% were due to medical necessity

· 13.1% were due to improper coding


In the 2018 CERT report, $31.6 billion of improper payments were due to:

· 58.0% were due to insufficient medical documentation

· 21.3% were due to medical necessity

· 11.9% were due to improper coding

In a recent report, CMS reported that the error rate dropped from 9.5% in 2017 to 8.1% in 2018…but resulted in Medicare losing $31.6 billion. Over the past six years, Medicare has lost more than $230 billion due to improper payments.

FY 2018 OIG, per their FY2020 Justification of Estimates for Appropriations Committees report, stated that their investigation efforts resulted in $2,766,390,715 in monetary results.

In their FY2019 budget performance report, the OIG stated the following results for FY 2017:

1. Referred 154 investigations for criminal prosecution / 17 for civil

2. Arrested 160 subjects, 52 of which have been sentenced in investigations that resulted in fines, seizures, restitution, penalties, and settlements of more than $639 million.

Negative impacts of non-compliance to business owners are as follows:

1. Criminal Prosecution

2. Civil Prosecution

3. Revocation of NPI and Billing Privileges

4. Six Month Payment Suspensions

5. Extrapolations With Look Back Periods of 36 Months

6. Recoupments

7. Denials and Audits Leading to Elevated Unbilled Revenue & Decreased Cashflow

What are the typical costs of compliance and privacy?

Compliance can be costly, albeit, no where near as costly as non-compliance. Here are some national averages of salaries for the typical roles that an organization would hire for internal positions.

Compliance Officer: $77,400

Compliance Specialist: $59,794

Privacy Officer: $77,995

Privacy Specialist: $55,597

Medical Records Auditor: $58,363

And keep in mind that any internal position means you are paying for non-productive hours (studies suggest up to 40% of the total time paid), in addition to, the following expenses:

1. Payroll Taxes

2. Benefits

3. Software Fees Per user

4. Workstations

5. SG&A

If you are like most, none of the above feels highly appealing. That is why Boost Advisory Group has created a customizable option that provides a highly beneficial approach to being compliant and profitable.

Boost offers monthly and quarterly compliance plans that will:

* Assess your current compliance and privacy programs and identify areas of non-compliance.

* Create and/or manage your corrective actions to eliminate areas of non-compliance

* Manage your compliance and/or privacy programs including communication channels, investigations, reporting, root cause analysis, and corrective actions

* Manage your business associate and non-disclosure agreements

* Manage your documentation authorization requests

* Conduct compliance reviews of billed claims to identify areas of non-compliance, and conduct outreach services for medical documentation if desired

* Assess SOP’s and management of SOP reviews

* Conduct OIG background checks for all employees

* Assess your compliance with TCPA and Medicare beneficiary contact and shipment rules

* Conduct new hire training, remedial training, and annual training

* Create and/or review employee disciplinary processes and forms

* Create your Code of Conduct

In addition to letting everyone know, and the peace of mind that it brings, the biggest benefit is Boost Advisory Group can do it for substantially less than you can. Here’s why.

1. You only pay for what you want and need. Everything is customized to your needs and budget

2. You are only paying for productive hours. Hours which Boost is actually working on your compliance and privacy programs.

a. No Paying for:

i. Vacation and break hours

ii. Personal days and sick days

iii. Meetings & smoking breaks

iv. Benefits

v. Payroll Taxes

vi. Access fees, software fees, workstations, overhead

vii. Surfing the internet, personal emails, personal text messages

3. You will have highly respected professionals supporting you; Both clinical experts and industry experts.

4. You qualify for 5-10% off all other Boost Advisory Group Services; no need to pay for expensive legal fees.

5. If any claim that is reviewed and approved by Boost Advisory Group is denied or fails an initial audit, Boost will appeal that DOS for FREE. We provide a 100% guarantee!

We truly hope that you learned a lot and now it is 100% your decision to decide if you want to play with fire and chance your compliance, go at it alone, or call us for a FREE consultation and proposal of what Boost Advisory Group can do for you.

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Boost Advisory Group are experts in DME consulting, DME revenue optimization, Brightree consulting and optimization, DME business process outsourcing, Medicare TPE, RAC, and UPIC audit response services, executive coaching, operational development, Analytics and reporting optimization to improve topline and bottom line. We are experts in helping our clients grow their business by reaching operational and financial excellence.

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