Compliance 1 a: the act or process of complying to a desire, demand, proposal, or regimen or to coercioncomplying 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 : flexibilityflexibility
OIG Most Wanted
Compliance in Ambulance Billing Who’s responsible? Management
Compliance in Ambulance Billing Who’s responsible? Field Crews
Compliance in Ambulance Billing Who’s responsible? Coders/Billers
Objectives Review OIG’s Ambulance Service Compliance Program Guidelines Review Self Audit Protocol
The Plan Federal Register/Vol.68, No.56 OIG Voluntary Program Guidance - Mandatory in 2014 Guidelines – Not A One Size Fits All Highly Recommended
Document Overview Produced June 2002 Outlines most common issues of fraud and abuse. Basically looks to: Identify Prevent Correct
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
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.
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.
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
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.
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.
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.
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?
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.
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.
Claims Submission Use baseline audit to develop benchmarks. Use external benchmarks as well. Document audit dates and outcomes. Use outcomes to drive training.
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!
Paid Claims Review Under/Overpayments An overpayment is one that has been received in excess amounts due and payable under Medicare statute and regulations.
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.
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.
Denials in RescueNet
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.
Sanctioned Suppliers It is your responsibility to check the websites for excluded individuals either in your employ or possibly going to be.
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
Response to Risks Develop written response protocols. Address issues in a timely manner. Document, document, document!
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.
Upcoding Charging ALS service charge for a BLS call. Charging for services not rendered.
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
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
Scheduled/Unscheduled Transports Obtain PCS Routine Doctor/Dialysis More appropriate transport available Do NOT submit inappropriate claims to Medicare.
Documentation, Billing & Reporting Inadequate/Faulty Documentation = High Risk Dispatch Transport Personnel Coders/Billers
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
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?
Part A Part A Agreements Contractual Agreements Not billable to Medicare High risk to violate Anti- Kickback Statute Medicaid 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.
Kickbacks and Inducements Be familiar with Safe Harbor regulations Referral Sources Municipal Contracts Ambulance Restocking Mutual Aid Agencies Hospitals and SNF’s
Additional Risks No transport Multiple Patient Multiple Agency Response Billing In Excess
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
Self Disclosure Provider Self Disclosure Protocol Voluntary Must be willing to “police” your own agency Correct underlying problems Work with government to reach resolution
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
Sources https://www.cms.gov/MLNProducts/downloads/OverpaymentBrochure pdf 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 https://www.cms.gov/MedicareContractingReform/Downloads/compliance.pdf