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2004 FPMP Compliance Plan Training Brigid M. Maloney, JD Compliance Officer (716) 829-3176 (716) 829-3176.

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Presentation on theme: "2004 FPMP Compliance Plan Training Brigid M. Maloney, JD Compliance Officer (716) 829-3176 (716) 829-3176."— Presentation transcript:

1 2004 FPMP Compliance Plan Training Brigid M. Maloney, JD Compliance Officer (716) 829-3176 (716) 829-3176

2 2004 Compliance Plan Reviewed and approved by the FPMP Governing Board, FPMP Compliance Committee, Clinical Chairs, and Practice Plan Auditors.

3 Elements of an Effective Compliance Plan  Code of Conduct and written policies and procedures  Compliance monitoring assigned to designated compliance officer or contact  Comprehensive training and education  Internal monitoring and auditing  Open lines of communication and updates  Disciplinary standards  Investigation and response to detected violations

4 Program Organization  FPMP Governing Board  FPMP Compliance Committee  Vice President for Health Affairs  FPMP Compliance Officer  Practice Plan Compliance Coordinators  Practice Plan Chart Auditors

5 Code of Conduct  Compliance with all laws, regulations, policies and procedures  Relationship with other providers  Claims with third party payors  Controlled substances  Confidential information  Conflict of Interest  Business information and relationships  Violations


7 1. Education & Training  Mandatory Annual Training: 2 hours biannually -educational sessions with your auditor -classes or seminars offered through FPMP Compliance Office -presentations made by outside consultants or medical billing specialists -off-site conferences and/or seminars covering healthcare compliance topics

8 Education & Training, cont’d Mandatory New Hire Training: All new clinical faculty must attend a 1-hour compliance orientation and training session with the FPMP Compliance Officer or his/her designee. New hire training sessions will be offered twice each year.

9 2. Documentation Complete and accurate medical record documentation is one of the most important objectives of the Compliance Plan, and a popular area of investigation by the Office of the Inspector General and US Attorney. Complete and accurate medical record documentation is one of the most important objectives of the Compliance Plan, and a popular area of investigation by the Office of the Inspector General and US Attorney.

10 Documentation, cont’d. The medical record may be used to validate:  Site of service  Appropriateness of services provided  Accuracy of the billing  Identity of the health care provider who furnished the services

11 Documentation, cont’d. All medical records must be complete and legible, and include the following: CC and/or reason for encounter CC and/or reason for encounter Relevant history Relevant history Physical examination & findings by physician Physical examination & findings by physician Prior diagnostic test results Prior diagnostic test results Assessment, clinical impression, or diagnosis Assessment, clinical impression, or diagnosis Plan of Care Plan of Care Date and legible identity of the observer A statement of the rationale for ordering diagnostic and other ancillary services, if not easily inferred. Risk factors, patient progress, response to changes in treatment, and any revision to diagnosis Addendums: dated the day the information is added to the medical record (not the date the service was provided).

12 Documentation, cont’d. Claims for professional fee reimbursement must:  Contain proper codes for service provided  Contain documentation that supports the codes  Be submitted in the name of the provider who performed the service.

13 Documentation, cont’d. Practice plan responsibilities:  Adopt FPMP Compliance Plan  Implement own documentation guidelines  Train and educate clinicians, coders, billers, administrative staff, and auditors

14 Documentation Some quotes from your peers concerning the E/M Guidelines:  Stupid (x2)  Compliance is impossible, "medically necessary" is impossible.  Will not improve care, will increase paperwork and will be used to intimidate physicians  Unnecessary and burdensome  Abusive, intrusive, outrageous, impossible to adhere to  Cumbersome, unnecessary, pain in the neck  Words do lie and liars can write  A process by which the federal government attempts to gain control over medicine  Justifying the jobs of bureaucrats and head hunters.  Part of a systematic breakdown of the physician-patient relationship  Increases my paperwork documentation time by about 25%, and I can charge nothing [for it]!  A vain attempt to painstakingly ascertain a physician's mental work product

15 3. Self Referrals & Kickbacks Anti-kickback Statute Stark Law

16 Anti-Kickback Statute It is unlawful to offer, pay, solicit, or receive any form of remuneration to induce or in return for:  Referring or arranging for any item or service payable under a federal health program; or  Buying, leasing, or ordering, any good, facility, service or item payable under a federal health care program.  Remuneration is defined broadly to include the transfer of anything of value, in cash or in kind, directly or indirectly.

17 Stark Law Stark II prohibits a physician from making a referral to an entity for the furnishing of designated health services (“DHS”) covered by Medicare if the physician (or an immediate family member of the physician) has a financial relationship with that entity, unless a statutory exception exists.

18 Stark Law “Designated Health Services”   clinical laboratory services;   physical therapy services;   occupational therapy services;   radiology services;   radiation therapy services;   durable medical equipment (DME) and supplies;  parenteral and enteral nutrients, equipment, and supplies;  prosthetics, orthotics, and prosthetic devices and supplies;  home health services;  outpatient prescription drugs; and  inpatient and outpatient hospital services.

19 Stark Law Referral-- A referral may be either a request for any DHS covered by Medicare, including consultations and the tests or procedures performed by the consulting physician, or a plan of care by a physician that includes any designated health service covered by Medicare. Financial Relationship— May be various types of payments, compensation or an ownership interest.

20 4. Reporting Misconduct  “All FPMP physicians and their employees are required to report any incidents of misconduct of which the physician or employee is directly aware or suspects.”  “Failure or refusal to report misconduct or fraudulent or illegal practices may result in disciplinary action, including termination.”

21 Examples of Misconduct  Improper coding  Inadequate medical record documentation  Falsification of medical records  Acceptance of bribes or other kickbacks  Unlawful attempt to induce referrals  Unlawful self-referrals  Retaliation against someone who has reported a compliance violation

22 5. Internal Audit & Monitoring  Practice plans are required to review the lesser of 2% of each physician’s submitted claims, or 20 claims per year.  Audit results are submitted to the FPMP Compliance Office.  If physician’s charts are found to be less than 70% compliant, then internal auditor must conduct an individual educational session and perform a follow-up audit.  Compliance rates of 50% or less on three consecutive audits will automatically trigger an investigation by the Medical Compliance Officer.

23 Auditing & Monitoring Top 10 coding errors 1. No documentation for services billed. 2. No signature or authentication of documentation. 3. Always assigning the same level of service. 4. Billing of consult vs. outpatient office visit. 5. Invalid codes billed due to old resources. 6. Unbundling of procedure codes. 7. Misinterpreted abbreviations. 8. No chief complaint listed for each visit. 9. Billing of service(s) included in global fee as a separate professional fee. 10. Inappropriate or no modifier used for accurate payment of claim.

24 6. Internal Investigations What triggers an internal investigation?  Complaint to the Medical Compliance Office  Irregularities identified through audits  Threat of civil litigation  Potential government investigation  Receipt of a subpoena

25 Goals of an Internal Investigation  Discover facts & circumstances surrounding alleged incidents of noncompliance  Assess legal significance of facts discovered  Evaluate legal rights and obligations of practice plan and physician  Determine if there has been deliberate wrongdoing  Stop the wrongdoing

26 7. Corrective Action  Mandatory education  Increased chart audits  Temporarily suspending billing  Mandatory prospective audits of all services before they are billed  Repayment or voluntary disclosure to appropriate payors or authorities  Termination from practice plan

27 8. Appeals procedure Any practice plan member who disagrees with the corrective action taken or proposed against him/her by the Medical Compliance Officer may appeal the corrective action.

28 9. Governmental Investigations Traditional areas targeted by government  Billing for services not rendered  Billing for services not medically necessary  Double billing  Upcoding  Unlawful kickbacks or referrals

29 What to do if an Investigator arrives  Obtain identification  Ask to see documents authorizing the investigation  Request purpose of investigator’s visit  Notify practice plan president or other individuals designated as contacts  Assure full cooperation with investigators  Remove all non-essential personnel from area  Suspend routine destruction of records  Maintain log of all events associated with investigation  Remember: staff may ask to be interviewed at a later date

30 10. Updates/Revisions  Minor revisions will be approved by the FPMP Compliance Committee  Major revisions must be approved by the Governing Board

31 Other FPMP Compliance Resources FPMP Quarterly Newsletter FPMP Quarterly Newsletter Compliance Committee meeting minutes Compliance Committee meeting minutes Auditing FAQ’s Auditing FAQ’s Practice Plan Training Guide Practice Plan Training Guide Individual Practice Plan Policies & Procedures Individual Practice Plan Policies & Procedures

32 A Sound Compliance Program Practice Plan FPMP Compliance Officer FPMP Compliance Committee PP Compliance Coordinator PP Auditor FPMP Governing Board FPMP Compliance Plan Newsletter Auditors meetingsEducational sessions Practice plan oversight Compliance plan review Training sessions Audit results reviewInvestigations Periodic audits Written standards Code of Conduct Reports violations Policy revisions Training Guide Compliance Oversight Corrective action

33 Brigid M. Maloney, J.D. Compliance Officer 3435 Main Street, BEB Rm. 149 Buffalo, New York 14214 (716) 829-3176

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