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This Session is CEU Approved

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2 This Session is CEU Approved

3 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 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

5 OIG Most Wanted

6 Compliance in Ambulance Billing Who’s responsible?  Management

7 Compliance in Ambulance Billing Who’s responsible?  Field Crews

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

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

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.

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.

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.

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  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.

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


47 Sources   pdf pdf   Section 1862(b)(6) of the Act (42 U.S.C. 1395y(b)(6))  

48 Sources  c_government2.html#B0ToaumFt9PHO4x2.99 c_government2.html#B0ToaumFt9PHO4x2.99

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