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Hashtag ZOLLSummit.

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Presentation on theme: "Hashtag ZOLLSummit."— Presentation transcript:

1 Hashtag ZOLLSummit

2 This Session is CEU Approved

3 Compliance…That’s Your Job
Compliance…That’s Your Job! Presented by: Renee Collier Implementation Specialist ZOLL

4 Compliance 1 a: the act or process of complying to a desire, demand, proposal, or regimen or to coercion b: conformity in fulfilling official requirements 2 : a disposition to yield to others 3: the ability of an object to yield elastically when a force is applied : flexibility

5 OIG Most Wanted

6 Compliance in Ambulance Billing
Who’s responsible? Management Management sets the tone for the expectation of compliance. As leaders, you should demonstrate your commitment to implementing and maintaining compliance standards.

7 Compliance in Ambulance Billing
Who’s responsible? Field Crews Field crews are responsible for knowing and understanding documentation requirements from their time of dispatch to patient drop-off. CMS wants a narrative of the patient assessment from the provider’s findings AND they want to see appropriate documentation particularly where transfers are involved. Field crews are responsible for knowing and meeting those requirements.

8 Compliance in Ambulance Billing
Who’s responsible? Coders/Billers

9 Objectives Review OIG’s Ambulance Service Compliance Program Guidelines Review Self Audit Protocol

10 The Plan Federal Register/Vol.68, No.56 OIG Voluntary Program Guidance
- Mandatory in 2014 Guidelines – Not A One Size Fits All Highly Recommended Recommend having one in place in case you are audited.

11 Document Overview Produced June 2002
Outlines most common issues of fraud and abuse. Basically looks to: Identify Prevent Correct Produced after soliciting comments and recommendations.

12 Areas of Concern Inappropriate Transports
Medically Unnecessary Transports Falsifying Trips Misrepresenting Destination Facility False Documentation Billing singly for group transport. Up-coding Payment of Kickbacks

13 What You Need Policies and Procedures Compliance Officer
Education & Training Programs Internal Reviews Response to Misconduct Communication Know what works for your organization - Tailor the plan for your specific risks/needs. (Needs/Risks assessment is a good place to start) look to see if this statement is applicable anywhere else or is stated any where else.

14 Policies and Procedures
Should describe normal operating procedures. Follows organizations rules and regulations. Implement intention to follow all laws and regulations. Should be internally developed and formally approved. If you can’t effectively perform a procedure – don’t incorporate it. Incorporating a statement that says you will review 100% of the PCR’s when you cannot effectively do that.

15 Compliance Officer Should be a management position
Should not be subordinate to General Counsel or Chief Financial Officer Oversees day-to-day compliance activities. Implement a Compliance Committee to assist in developing a Compliance Program

16 Training and Education
Organizational and Job Specific Employees should understand the elements and importance of the program. Ensure employees know who is responsible for maintaining the program. Specifically let employees know what this means to them. Make available to all employees even if they are not directly involved with patient care or billing.

17 Training and Education
Specific to job responsibilities. Cross train to improve individual awareness of compliance issues. Interactive environment where participants can ask questions and offer their feedback. Allow field crews and billing personnel to develop and lead the training based on “real” examples.

18 Training and Education
OIG does not endorse a particular training program. Develop your own. Internet or web based are acceptable. Provide a test after the training to ensure employees understand the information. Keep materials updated. Keep records of training dates, curriculum and attendance.

19 Claims Submission Assessment
Conduct reviews of claims either ready to submit or submitted and paid. Is the patient information correct? Is the Narrative documented correctly? Was there Medical Necessity? Properly coded? Co-payment collected appropriately? Payor Reimbursement handled appropriately?

20 Claims Submission Use independent reviewers
Can focus on one high risk area or may include the entire claim. Universe of claims to choose from. Basically you choose a date range and then pull random PCR’s to review. Independent Reviewers would be others that did not process that particular claim. OIG has no recommended percentage of calls to review, but should be enough so that the results are representative of the entire “universe”.

21 Claims Submission Monitor/Identify Error Cause
Document that you identified the cause and steps taken to mitigate the issue. It is the Ambulance supplier’s responsibility to identify and rectify weaknesses immediately.

22 Claims Submission Use baseline audit to develop benchmarks.
Use external benchmarks as well. Document audit dates and outcomes. Use outcomes to drive training.

23 Pre-Billing Review Look for appropriate documentation. Pre-Bill?
Medical Necessity Narrative Coded Correctly If not complete, do not submit the claim! You SHOULD be doing this with every claim!

24 Paid Claims Review Under/Overpayments
An overpayment is one that has been received in excess amounts due and payable under Medicare statute and regulations.

25 Paid Claims Review What causes overpayments?
Duplicate submission of same service or claim Payment to the incorrect payee Payment for excluded/medically unnecessary services. Pattern of providing and billing for excessive or non-covered services. Any overpayments found should be returned to the Payor immediately.

26 Claims Denials Review You should already be reviewing your denials!
Review to determine if there is a pattern in your denials. Determine the cause. If internal, address it through training in proper documentation, coding and medical necessity. If the Payor is systematically denying your claims, ask for clarification in writing.

27 Denials in RescueNet

28 System Reviews and Safeguards
Dispatch to payment tracking processes. Allows the supplier to identify deficiencies. Especially important when changing billing software or claims vendor. Communicate with Payors when making big system changes to alert them to delays, increase or decrease in submissions. Go through software Billing program step by step and ensure that you do not have system defaults active.

29 Sanctioned Suppliers It is your responsibility to check the websites for excluded individuals either in your employ or possibly going to be.

30 Identification of Risks
Different area of risks depending on service size. Identify those specific to your service and plan to mitigate those. Keep up to date with Fraud Alerts and Publications at

31 Response to Risks Develop written response protocols.
Address issues in a timely manner. Document, document, document!

32 Specific Fraud and Abuse Risks
Medical Necessity Varies between non-emergency and emergency transports. Medics, Billers and Management need to understand the difference. Refer to your MAC to obtain a Guide for Ambulance Providers and for your specific Local Coverage Determination list.

33 Upcoding Charging ALS service charge for a BLS call.
Charging for services not rendered.

34 Non-Emergency Transports
High Risk for fraud and abuse Must meet Medical Necessity Always document accurately whether or not you believe Medicare will pay. Ensure crews document patient condition accurately. Acronyms in Documentation

35 EMS Acronyms DRT- Dead Right There FTD- Fixing to Die
CTD – Circling the Drain DDPI – Death Despite Paramedic Interference HIBGIA- Had it Before, Got it Again FDSD – Found Dead, Stayed Dead PEP – Pharmaceutically Enhanced Personality ID-10-T on Scene

36 Scheduled/Unscheduled Transports
Obtain PCS Routine Doctor/Dialysis More appropriate transport available Do NOT submit inappropriate claims to Medicare.

37 Documentation, Billing & Reporting
Inadequate/Faulty Documentation = High Risk Dispatch Transport Personnel Coders/Billers

38 Minimum Information Dispatch instructions
Why Ambulance transport was needed Level of Service required Patient Status Trip Ordered by? Trip Times: Dispatch, Arrival and Destination Mileage Pickup/Destination Codes/HCPCS Services provided/Loaded Miles

39 Coordination of Benefits
There are times when you will not have insurance information for secondary Payor. If you “double-bill” for a trip and it gets paid, you are accountable to re-pay the overpayment within 60 days. If investigated and overpayment is found, they can charge interest and double the original amount. Fines?

40 Part A Part A Agreements Medicaid Contractual Agreements
Not billable to Medicare High risk to violate Anti- Kickback Statute Individual to each state States that receive Medicaid funds must provide transportation to recipients to and from Medical appointments. Federal regulations define medical transportation and describe reimbursable costs.

41 Kickbacks and Inducements
Be familiar with Safe Harbor regulations Referral Sources Municipal Contracts Ambulance Restocking Mutual Aid Agencies Hospitals and SNF’s

42 Additional Risks No transport Multiple Patient
Multiple Agency Response Billing In Excess

43 Discovery Any issues discovered that could be a potential criminal, civil or administrative violation may be disclosed to the OIG Provider Self Disclosure Protocol - Federal Register/Vol. 63, No. 210 RAT-STATS

44 Self Disclosure Provider Self Disclosure Protocol Voluntary
Must be willing to “police” your own agency Correct underlying problems Work with government to reach resolution

45 Knowledge will forever govern ignorance; and a people who mean to be their own governors must arm themselves with the power which knowledge gives. - James Madison

46

47 Sources http://www.merriam-webster.com/dictionary/compliance
https://www.cms.gov/MLNProducts/downloads/OverpaymentBrochure pdf Section 1862(b)(6) of the Act (42 U.S.C. 1395y(b)(6)) https://www.cms.gov/MedicareContractingReform/Downloads/compliance.pdf

48 Sources c_government2.html#B0ToaumFt9PHO4x2.99


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