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Corporate Compliance Education 2009 Presented by Thom Sinnette VA-NWIHCS Compliance Officer.

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Presentation on theme: "Corporate Compliance Education 2009 Presented by Thom Sinnette VA-NWIHCS Compliance Officer."— Presentation transcript:

1 Corporate Compliance Education 2009 Presented by Thom Sinnette VA-NWIHCS Compliance Officer

2 Why Corporate Compliance? To ensure compliance with federal and state laws and regulations To ensure compliance with federal and state laws and regulations To promote the prevention, detection and resolution of conduct that does not conform to requirements applicable to ethical business practices. To promote the prevention, detection and resolution of conduct that does not conform to requirements applicable to ethical business practices.

3 7 Elements of a Program Establish compliance standards and procedures Establish compliance standards and procedures Make high-level personnel responsible for overseeing compliance. Make high-level personnel responsible for overseeing compliance. Use care to avoid delegating substantial discretionary authority to individuals whom the organization knows, or should have known, have a propensity to engage in illegal activities. Use care to avoid delegating substantial discretionary authority to individuals whom the organization knows, or should have known, have a propensity to engage in illegal activities. Effectively communicate standards and procedures to all employees and agents. Effectively communicate standards and procedures to all employees and agents. Take reasonable steps to achieve compliance with standards, including using monitoring and auditing systems and publicizing a system for employees to use to report violations of code standards, as well as criminal conduct, without fear of retribution. Take reasonable steps to achieve compliance with standards, including using monitoring and auditing systems and publicizing a system for employees to use to report violations of code standards, as well as criminal conduct, without fear of retribution. Consistently enforce the standards through appropriate disciplinary mechanisms. Consistently enforce the standards through appropriate disciplinary mechanisms. Take all reasonable steps to respond appropriately and prevent further similar offenses, when an offense is detected. Take all reasonable steps to respond appropriately and prevent further similar offenses, when an offense is detected.

4 Corporate Compliance Programs Focus on compliance with fraud and abuse laws; Civil False Claims Act provides civil remedy against those who defraud the government (Knowingly submit false claim) Anti-Kickback statutes Prohibits knowing and willful offer/payment of remuneration in cash or in kind to induce referrals Stark Law restrictions on physician self-referrals

5 Definitions Fraud: Intentional deception or mis- representation that an individual or organization makes such as a false statement/claim to the Medicare program. Fraud: Intentional deception or mis- representation that an individual or organization makes such as a false statement/claim to the Medicare program. Abuse: Incidents or practices which are inconsistent with accepted sound medical, business or fiscal practices and directly or indirectly create unnecessary costs to the Medicare program Abuse: Incidents or practices which are inconsistent with accepted sound medical, business or fiscal practices and directly or indirectly create unnecessary costs to the Medicare program

6 Examples of Fraud Billing for services not rendered (not documented) Billing for services not rendered (not documented) Soliciting, offering, or receiving a kickback, bribe or rebate Soliciting, offering, or receiving a kickback, bribe or rebate Using an incorrect or inappropriate provider number to be paid Using an incorrect or inappropriate provider number to be paid Signing blank records or certification forms to obtain Medicare payment Signing blank records or certification forms to obtain Medicare payment Offering incentives to Medicare patients not offered to non-Medicare patients (e.g., waiver of deductible/coinsurance) Offering incentives to Medicare patients not offered to non-Medicare patients (e.g., waiver of deductible/coinsurance) Falsifying information on medical records or billing statements Falsifying information on medical records or billing statements Misrepresenting as medically necessary, non-covered services by using inappropriate procedure or diagnosis codes Misrepresenting as medically necessary, non-covered services by using inappropriate procedure or diagnosis codes

7 Examples of Abuse Using procedure or revenue codes that describe more intensive services than actually performed Using procedure or revenue codes that describe more intensive services than actually performed Routinely submitting duplicate claims Routinely submitting duplicate claims Billing for services in excess of those needed by patients Billing for services in excess of those needed by patients Billing for services more expensive than used Billing for services more expensive than used

8 What does this mean? Government will be aggressive Government will be aggressive Increased scrutiny of claims Increased scrutiny of claims Coding and documentation Coding and documentation Critical Care Critical Care Consultations Consultations Pre-operative history and physical Pre-operative history and physical

9 Physician Documentation is main cause of “Compliance Failures” 4 categories of errors 1) Medical record contains insufficient documentation to determine patient’s condition or diagnosis warranting service 2) Service was performed but documentation did not indicate service was medically necessary 3) Claims filed for noncovered services and miscellaneous coding errors 4) Service was coded at a higher level than supported by the relevant medical record

10 Physician Responsibilities Physician Responsibilities Order individual tests (not group or routine) Order individual tests (not group or routine) Provide specific diagnostic information (ICD-9) at the time of the order for each testing Provide specific diagnostic information (ICD-9) at the time of the order for each testing Ensure sufficient documentation to justify procedure/service code Ensure sufficient documentation to justify procedure/service code

11 Physician Compliance Medical Record should be complete and legible Each patient encounter should include: Each patient encounter should include: Reason for encounter and relevant history Reason for encounter and relevant history Physical exam Physical exam Diagnostic test results Diagnostic test results Assessment Assessment Clinical impression Clinical impression Plan for care Plan for care Date and legible identity of provider Date and legible identity of provider Appropriate health risk factors should be identified Appropriate health risk factors should be identified Patient’s response to and any changes in treatment or revision in diagnosis is documented Patient’s response to and any changes in treatment or revision in diagnosis is documented

12 Documentation…Key points! Every service billed must be documented. There must be clear evidence in the patient’s record that the service, procedure, or supply was actually performed or supplied. Every service billed must be documented. There must be clear evidence in the patient’s record that the service, procedure, or supply was actually performed or supplied. The medical necessity for choosing the procedure, service or medical supply must be substantiated. The medical necessity for choosing the procedure, service or medical supply must be substantiated. Every service must be coded correctly. Diagnoses must be coded to the highest level of specificity, and procedures codes must be current. Every service must be coded correctly. Diagnoses must be coded to the highest level of specificity, and procedures codes must be current. The documentation must clearly indicate who performed the procedure or supplied the equipment. The documentation must clearly indicate who performed the procedure or supplied the equipment. Although it may be dictated and transcribed, legible documentation is required. Existing documentation may not be embellished (e.g. adding what was omitted in the initial documentation); however, additional documentation that supports a claim may be submitted. Although it may be dictated and transcribed, legible documentation is required. Existing documentation may not be embellished (e.g. adding what was omitted in the initial documentation); however, additional documentation that supports a claim may be submitted.

13 Teaching Physician Rules (42 CFR § ) General rule: Teaching physician should be present during any service in which he/she involves a resident General rule: Teaching physician should be present during any service in which he/she involves a resident Teaching physician must be physically present during the portion of the service that determines the level of E&M service billed Teaching physician must be physically present during the portion of the service that determines the level of E&M service billed Teaching physician must personally document his/her presence in services via writing or dictated note (summarize resident’s assessment) Teaching physician must personally document his/her presence in services via writing or dictated note (summarize resident’s assessment)

14 Teaching Physician Rules Psychiatry Psychiatry Teaching physician supervising resident must be a physician Teaching physician supervising resident must be a physician Concurrent observation of service may be met by use of one-way mirror or video equipment Concurrent observation of service may be met by use of one-way mirror or video equipment Audio alone does not meet this exception Audio alone does not meet this exception

15 Teaching Physician Rules Time Based Codes Time Based Codes For procedure codes specifying time, the teaching physician must be present for the time which the claim is made For procedure codes specifying time, the teaching physician must be present for the time which the claim is made Time spent by the resident alone cannot be added to the time spent by the teaching physician Time spent by the resident alone cannot be added to the time spent by the teaching physician Individual medical psychotherapy ( ) Individual medical psychotherapy ( ) Critical Care codes ( ) Critical Care codes ( ) Prolonged services ( ) Prolonged services ( ) Care plan oversight (99375) Care plan oversight (99375) Anesthesia Anesthesia

16 Teaching Physician Rules Interpretation of Diagnostic Radiology and Other Diagnostic tests Interpretation of Diagnostic Radiology and Other Diagnostic tests If Resident prepares and signs interpretation of diagnostic tests, the teaching physician must indicate he/she has also personally reviewed the test/image and resident’s interpretation and either agrees with it or edits its findings If Resident prepares and signs interpretation of diagnostic tests, the teaching physician must indicate he/she has also personally reviewed the test/image and resident’s interpretation and either agrees with it or edits its findings Countersignature alone is not sufficient documentation Countersignature alone is not sufficient documentation


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