3Compliance…That’s Your Job Compliance…That’s Your Job! Presented by: Renee Collier Implementation Specialist ZOLL
4Compliance1 a: the act or process of complying to a desire, demand, proposal, or regimen or to coercionb: conformity in fulfilling official requirements2 : a disposition to yield to others3: the ability of an object to yield elastically when a force is applied : flexibility
6Compliance in Ambulance Billing Who’s responsible?ManagementManagement sets the tone for the expectation of compliance. As leaders, you should demonstrate your commitment to implementing and maintaining compliance standards.
7Compliance in Ambulance Billing Who’s responsible?Field CrewsField 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.
8Compliance in Ambulance Billing Who’s responsible?Coders/Billers
9ObjectivesReview OIG’s Ambulance Service Compliance Program GuidelinesReview Self Audit Protocol
10The Plan Federal Register/Vol.68, No.56 OIG Voluntary Program Guidance - Mandatory in 2014Guidelines – Not A One Size Fits AllHighly RecommendedRecommend having one in place in case you are audited.
11Document Overview Produced June 2002 Outlines most common issues of fraud and abuse.Basically looks to:IdentifyPreventCorrectProduced after soliciting comments and recommendations.
12Areas of Concern Inappropriate Transports Medically Unnecessary TransportsFalsifying TripsMisrepresenting Destination FacilityFalse DocumentationBilling singly for group transport.Up-codingPayment of Kickbacks
13What You Need Policies and Procedures Compliance Officer Education & Training ProgramsInternal ReviewsResponse to MisconductCommunicationKnow 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.
14Policies 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.
15Compliance Officer Should be a management position Should not be subordinate to General Counsel or Chief Financial OfficerOversees day-to-day compliance activities.Implement a Compliance Committee to assist in developing a Compliance Program
16Training and Education Organizational and Job SpecificEmployees 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.
17Training 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.
18Training 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.
19Claims 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?
20Claims 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”.
21Claims 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.
22Claims Submission Use baseline audit to develop benchmarks. Use external benchmarks as well.Document audit dates and outcomes.Use outcomes to drive training.
23Pre-Billing Review Look for appropriate documentation. Pre-Bill? Medical NecessityNarrativeCoded CorrectlyIf not complete, do not submit the claim!You SHOULD be doing this with every claim!
24Paid Claims Review Under/Overpayments An overpayment is one that has been received in excess amounts due and payable under Medicare statute and regulations.
25Paid Claims Review What causes overpayments? Duplicate submission of same service or claimPayment to the incorrect payeePayment 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.
26Claims 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.
28System 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.
29Sanctioned SuppliersIt is your responsibility to check the websites for excluded individuals either in your employ or possibly going to be.
30Identification 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
31Response to Risks Develop written response protocols. Address issues in a timely manner.Document, document, document!
32Specific Fraud and Abuse Risks Medical NecessityVaries 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.
33Upcoding Charging ALS service charge for a BLS call. Charging for services not rendered.
34Non-Emergency Transports High Risk for fraud and abuseMust meet Medical NecessityAlways document accurately whether or not you believe Medicare will pay.Ensure crews document patient condition accurately.Acronyms in Documentation
35EMS Acronyms DRT- Dead Right There FTD- Fixing to Die CTD – Circling the DrainDDPI – Death Despite Paramedic InterferenceHIBGIA- Had it Before, Got it AgainFDSD – Found Dead, Stayed DeadPEP – Pharmaceutically Enhanced PersonalityID-10-T on Scene
36Scheduled/Unscheduled Transports Obtain PCSRoutine Doctor/DialysisMore appropriate transport availableDo NOT submit inappropriate claims to Medicare.
37Documentation, Billing & Reporting Inadequate/Faulty Documentation = High RiskDispatchTransport PersonnelCoders/Billers
38Minimum Information Dispatch instructions Why Ambulance transport was neededLevel of Service requiredPatient StatusTrip Ordered by?Trip Times: Dispatch, Arrival and DestinationMileagePickup/Destination Codes/HCPCSServices provided/Loaded Miles
39Coordination 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?
40Part A Part A Agreements Medicaid Contractual Agreements Not billable to MedicareHigh risk to violate Anti- Kickback StatuteIndividual to each stateStates that receive Medicaid funds must provide transportation to recipients to and from Medical appointments.Federal regulations define medical transportation and describe reimbursable costs.
41Kickbacks and Inducements Be familiar with Safe Harbor regulationsReferral SourcesMunicipal ContractsAmbulance RestockingMutual Aid AgenciesHospitals and SNF’s
42Additional Risks No transport Multiple Patient Multiple Agency ResponseBilling In Excess
43DiscoveryAny issues discovered that could be a potential criminal, civil or administrative violation may be disclosed to the OIGProvider Self Disclosure Protocol- Federal Register/Vol. 63, No. 210RAT-STATS
44Self Disclosure Provider Self Disclosure Protocol Voluntary Must be willing to “police” your own agencyCorrect underlying problemsWork with government to reach resolution
45Knowledge 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