BENEFITS OF A HEALTHCARE COMPLIANCE PROGRAM

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Reality versus Perception

By Carol Miller RN MHA

Carol S. MillerThere are many associated benefits of a healthcare or medical practice compliance program, some of which are only perceived whereas others are very definitive.  Most providers try to comply with the rules and regulations and what is or is not covered by different insurance programs.

Risk Management and Quality Initiatives

Regardless of their ethical and quality processes in their office practice, the decision to develop and implement a compliance program still is an important and needed business decision.  The processes involved in a compliance program can help improve the organization’s performance by providing basic principles in quality improvement which can help improve the provider’s bottom line.

The Benefits

Several benefits of a compliance program are:

  • Improving the quality of patient care
  • Servicing as a resource for information about compliance-related issues
  • Saving time, money, and associated apprehensions during audits or reviews
  • Preventing or identifying improper conduct with systems for evaluation and correction
  • Providing training for employees and contracted services to recognize fraud and abuse
  • Providing a way for employees to report potential problems
  • Demonstrating to staff and community that the practice is committed to honesty and appropriate conduct
  • Minimizing loss associated with false claims through early recognition and reporting, and decreasing the provider’s exposure to civil penalties, sanctions and other administrative actions, such as exclusion

The OIG

The OIG has developed a series of voluntary compliance program guidance documents directed at various segments of the healthcare industry, such as hospitals, nursing homes, third-party billers, durable medical equipment suppliers, clinical laboratories, home health agencies, hospices, nursing facilities, ambulance suppliers, pharmaceutical manufacturers, physician practices, and others, to encourage the development and use of internal controls to monitor adherence to statutes, regulations and program requirements.

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Safe

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Fraud and Abuse, Too!

The OIG documents also identify fraud and abuse risks to watch out for when creating a programs

ABOUT

Ms. Carol S. Miller has an extensive healthcare background in operations, business development and capture in both the public and private sector. Over the last 10 years she has provided management support to projects in the Department of Health and Human Services, Veterans Affairs, and Department of Defense medical programs. In most recent years, Carol has served as Vice President and Senior Account Executive for NCI Information Systems, Inc., Assistant Vice President at SAIC, and Program Manager at MITRE. She has led the successful capture of large IDIQ/GWAC programs, managed the operations of multiple government contracts, interacted with many government key executives, and increased the new account portfolios for each firm she supported. She earned her MBA from Marymount University; BS in Business from Saint Joseph’s College, and BS in Nursing from the University of Pittsburgh. She is a Certified PMI Project Management Professional (PMP) (PMI PMP) and a Certified HIPAA Professional (CHP), with Top Secret Security clearance issued by the DoD in 2006. Ms. Miller is also a HIMSS Fellow.

CASE MODEL: Compliance

Assessment

The documents provide principles to follow when developing a compliance program that best suits the organization’s needs.

Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Risk Assessment of Medical Practice Billing Companies

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Office of Inspector General

trites

[By Pati Trites MPA, CHBC with Staff Reporters]

The Office of Inspector General [OIG] believes a medical billing company’s written policies and procedures, its educational program and its audit and investigation plans should take into consideration the particular statutes, rules and program instructions that apply to each function or department of the billing company.

Co-ordination Needed

Consequently, coordination between these functions is needed, with an emphasis on areas of special concern that have been identified by the OIG through its investigative and audit functions.

Furthermore, the OIG recommends that billing companies conduct a comprehensive self-administered risk analysis or contract for an independent risk analysis by experienced health care consulting professionals. This risk analysis should identify and rank the various compliance and business risks the company may experience in its daily operations.

Risk Analysis

Once completed, the risk analysis should serve as the basis for the written policies the billing company should develop. The OIG provides the following specific list of particular risk areas that should be addressed by billing companies. It should be noted that this list is not all-encompassing and the risk analysis completed as a result of the company’s audit may provide a more individualized roadmap. Nonetheless, this list is a compilation of several years of OIG audits, investigations and evaluations and should provide a solid starting point for a company’s initial effort.

Problem List

Among the risk areas the OIG has identified as particularly problematic are:

  • Billing for items or services not actually documented;
  • Unbundling;
  • Upcoding, such as, for example, “DRG creep;
  • Inappropriate balance billing;
  • Inadequate resolution of overpayments;
  • Lack of integrity in computer systems;
  • Computer software programs that encourage billing personnel to enter data in fields indicating services were rendered though not actually performed or documented;
  • Failure to maintain the confidentiality of information/records;
  • Knowing misuse of provider identification numbers, which results in improper billing;
  • Outpatient services rendered in connection with inpatient stays;
  • Duplicate billing in an attempt to gain duplicate payment;
  • Billing for discharge in lieu of transfer;
  • Failure to properly use modifiers;
  • Billing company incentives that violate the anti-kickback statute or other similar Federal or State statute or regulation;
  • Joint ventures;
  • Routine waiver of copayments and billing third-party insurance only; and
  • Discounts and professional courtesy.

Additional Risk Areas

The physician-executive should understand that a billing company’s prior history of noncompliance with applicable statutes, regulations and Federal health care program requirements may indicate additional types of risk areas where the billing company may be vulnerable and may require necessary policy measures to prevent avoidable recurrence.

Additional risk areas should be assessed by billing companies as well as incorporated into the written policies and procedures and training elements developed as part of their compliance programs.

Assessment 

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Billing companies that do not code bills should implement policies that require notification to the provider who is coding to implement and follow compliance safeguards with respect to documentation of services rendered.

Moreover, the OIG recommends that billing companies who do not code for their provider clients incorporate in their contractual agreements the provider’s acknowledgment and agreement to address the above coding compliance safeguards.

Conclusion

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Understanding the Healthcare Fraud and Abuse Control Program

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A Joint Project Between the OIG and DOJ

PT

By Patricia Trites; MPA, CHBC, CPC

The Healthcare Fraud and Abuse Control (HCFAC) program is a joint project between the Office of Inspector General [OIG] and the Department of Justice (DOJ).

Functions

The primary functions are to coordinate federal, state, and local enforcement in controlling healthcare fraud, and to conduct investigations relating to delivery and payment of healthcare services, and oversee Medicare and Medicaid exclusions, civil money penalties, and the anti-kickback law. The program is also designed to provide opinions, alerts, and a means for reporting and disclosing final adverse actions against healthcare providers.

HIPAA Policies

HIPAA established the Health Care Fraud and Abuse Control Account within the Medicare Part A Trust Fund and funds DOJ and DHHS activities for operation of the HCFAC. In addition to federal appropriations, the fund receives a portion of funds collected from healthcare fraud and abuse penalties and fines. HIPAA also authorizes funds from general revenues for the Federal Bureau of Investigation (FBI) to combat healthcare fraud and abuse.

Assessment

Anti-fraud and abuse provisions were also included in the Balanced Budget Act of 1997 and the Deficit Reduction Act [DRA] of 2005, and annotated and

Conclusion

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Tightening Payment Rules for Non-Physicians

Understanding the Medicare “Incident To” Rules

By Staff ReportersGator

Under the “incident to” rules, Medicare Part B pays for some services that are billed by physicians, but performed by non-physicians. And, the Department of Health and Human Services [DHHS] and Office of Inspector General [OIG] says that some of these services might be used improperly.

Suggestions to CMS

The agency recommends the Centers for Medicare & Medicaid Services [CMS] perform the following:

  • Revise the “incident to” rule to require that physicians who bill Medicare, but don’t perform the services themselves, ensure that the services are provided by a licensed physician, or a non-physician with the necessary training, certification or licensure.
  • Require that physicians who use non-physician services identify this with a service code modifier on bills.
  • Take appropriate action to detect when physicians bill for “incident to” services that are not covered under the rule.

Assessment

In the current healthcare reform environment, Medicare services by non-physicians are coming under increased scrutiny. And, the OIG is finding that the “incident to” rule is allowing medical care to be provided by non-physicians who may lack the necessary qualifications. This may be a healthcare financial, insurance and quality breach. So, don’t let this trap “bite” you.

Source: HHS Office of Inspector General (www.oig.hhs.gov/oei/reports/oei-09-06-00430.pdf)

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Has anyone been bitten by the ‘incident to” rules? Tell us what you think. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Understanding Periodic or New Employee Practice Compliance Audits

Perform and Improve as Needed

By Patricia Trites MPA, CHBC; with Staff Reporters 

www.HealthcareFinancials.comho-journal12

There are several types of compliance audits that a medical practice, clinic or healthcare organization might need to perform. The starting point, discussed elsewhere on this ME-P, is to obtain a baseline audit. The next step is periodic audits or reviews that are performed after information is obtained from the baseline audit.

Periodic Audits

Periodic audits are performed on an on-going basis. Depending on the volume of billing, these may occur weekly for a large multi-specialty ambulatory clinic to quarterly for a small medical practice. These periodic audits can be random or scheduled. Sometimes in the process of seeing how things run, a surprise review can be informative to staff and practitioners.

New Employee Audits

New employees require regular training and reviews until there is confidence in their capabilities. Background checks are often helpful to find out whether there are any potential conflicts. In hospitals, health plan offices, surgery centers, and other regulated facilities, background checks are a normal part of the credentialing process. This process typically includes Medicare violations, which would show up on the National Practitioner Data Bank report. However, independent medical practices do not have access to this type of information and may have to rely on other organizations to obtain the information. The OIG and the General Services Administration both maintain a database of excluded persons and entities that can be accessed through the Internet. As part of the organization’s initial and periodic audits, queries of these two databases should be performed for all employees and independent contractors (like locum tenens physicians). Failure to do so can put the practice at risk of large civil money penalties ($10,000 for each occurrence) and liability for refunds of all claims the excluded individual had part in providing or billing.

Assessment

Additional audits can be performed whenever new employees are added, or if there are complaints or issues that arise in the course of business; prn.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated? What interesting, informative or strange tidbits have you uncovered in your auditing processes?

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