1. UBO Compliance Program Requirements DHA UBO Contract Support Team
26 August 2014 at EST
28 August 2014 at EST
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2. Agenda/Objectives
Understand what compliance is and why it is needed
Understand compliance program requirements and best practices
roles and responsibilities for UBO program
quarterly audits
Understand recent changes to the DOD UBO Compliance Audit Checklist and how to effectively use it
Understand billing risk areas
Find ways to improve your compliance program
Compliance resources

3. What is Compliance?
To monitor the organization to ensure consistent application of laws and rules relating to the MTF billing process
To ensure ethical billing and collections by identifying problem areas and to establish and implement solutions. The programmatic elements will include, but will not be limited to:
Medical records documentation
Data quality/coding
Billing
Accounting and fiscal law
Healthcare fraud, waste, and abuse

4. Why Compliance?
Advantages
Sets processes
Promotes efficiency
Supports the overall mission of providing quality health care
Protects against mistakes
Helps detect mistakes
Helps detect fraud (not anti-fraud)
Helps you develop internal controls
Promote adherence to federal law
IS REQUIRED (next slide)

5. Definitions
Must
requirements created by statute or regulation; no discretion
Should
expectations identified in guidelines; discretion as to how you accomplish effectiveness
Best Practices
procedures that work well for some facilities; may not work for all

6. Federal Managers Financial Integrity Act of 1982 (FMFIA)
Authorities
Federal Managers Financial Integrity Act of 1982 (FMFIA)
Requires DoD to implement & assess the effectiveness of financial management internal control
OMB Circular A-123, Management’s Responsibility for Internal Control, and Appendix A, Internal Controls Over Financial Reporting (ICOFR)
Revenues and expenditures are properly recorded and accounted for on financial and statistical reports
Chief Financial Officer’s Act of 1990 (CFO Act)
Goal: Achieve reliable financial data & safeguard resources from Fraud, Waste & Abuse (FW&A)

7. Authorities
OASD(HA)/TMA Memo, “Compliance Plan Implementation Policy” to ensure that MTFs establish and comply with compliance guidelines (Feb 28, 2002)
Establish a compliance plan focused on coding and billing ethical conduct
Perform a compliance audit, using an effective audit tool, at least quarterly

8. Authorities
ASD(HA) Memo, “Revision of Compliance Audit Requirements in the DOD M, “MTF UBO Manual, Nov 9, 2006”” (Feb 27, 2008)
Implements Third Party Collection quarterly audit requirements per DOD IG Report NO. D “Outpatient Third Party Collection Program” (July 18, 2007)
Bills are generated and sent for patient encounters when other health insurance information exists in CHCS.
Collections from insurance providers are adequately followed up.
All errors and deficiencies found during audits are corrected.

9. Applies to anyone billing under Title 10 of the United States Code
Authorities
DoD M– Military Treatment Facility Uniform Business Office (UBO) Manual
Applies to anyone billing under Title 10 of the United States Code
10 USC 1095: Health care services incurred on behalf of covered beneficiaries: collection from third-party payers
10 USC 1079b: Procedures for charging fees for care provided to civilians
10 USC 1085: Medical and dental care from another executive department: reimbursement
Chapter 2 – Compliance (currently under revision)
This guidance document shall be used as a tool to develop effective internal controls that promote adherence to applicable Federal laws relating to healthcare billing requirements
Applies to the MSA, TPC, and MAC programs as well as any other healthcare billing activities designated by the Department of Defense, such as resource sharing agreements
Applies to all UBOs (i.e., government and civilian contractor staffed)

10. The compliance audit must verify:
Authorities
The compliance audit must verify:
1. Internal controls identified in this Manual and on the UBO Compliance Audit Checklist have been implemented.
2. Requirements for storage and deposit of funds are met.
3.* MTFs have billed insurance providers for patient encounters where other health insurance information exists in the Composite Health Care System pursuant to reference (ae).
4.* MTFs have adequately followed up on collections from insurance providers pursuant to reference (ae).
* MTFs must correct deficiencies that they found in the TPCP during the compliance audits pursuant to reference (ae).
* NEW, added to upcoming revision of UBO Manual pursuant to ASD(HA) Memorandum, “Revision of Compliance Audit Requirements in the Department of Defense M, “Military Treatment Facility Uniform Business Office Manual, “ November 9, 2006” (Feb 27, 2008)

11. Authorities
Sections 6102 and 6401 of the Patient Protection and Affordable Care Act (PPACA) mandate that skilled nursing facilities (SNF), nursing facilities (NF), and other health care providers and suppliers enrolled in Medicare, Medicaid, and the Children's Health Insurance Program adopt compliance programs as a condition of enrollment by March 23, 2013
Department of Health and Human Services has not yet promulgated regulations. In the interim, may still look to the HHS Office of Inspector General (OIG) Compliance Program Guidance (similar to DHA UBO program)
The OIG's voluntary compliance program guidance documents available at 

12. Minimum Program Requirements
Written policies and procedures
including standards of conduct to validate compliance commitment
Compliance professional
not the UBO Manager, should have direct access to MTF Executive Committee
Effective training
regular, complete and documented programs with periodic updates
Effective communication
encourage feedback, communicate non-retaliation, be visible
Internal monitoring
audits and other evaluation techniques to monitor compliance
Enforce your standards
wide publication of standards, reporting and disciplinary guidelines
Promptly respond to issues
respond to alleged offenses and develop corrective action initiatives

13. Roles and Responsibilities
Compliance Officer (CO)
Oversees/monitors execution of compliance program
Ensures components of compliance program are executed
Communicates compliance program & coding/billing policies & procedures
Compliance Committee
Advises CO and aids in execution of compliance program
Monitors internal program controls
Ensures periodic audits are performed
Ensures implementation of internal fiscal/administrative controls
MTF personnel
should review their specific Compliance Audit Checklist and worksheets to understand their program’s audit requirements
Provide UBO CO with requested audit information
must correct any errors or deficiencies identified during audit
Attend trainings, ask questions and report discrepancies

14. DHA Compliance Audit Toolkit
Available on the DHA UBO website at
Anti-Fraud Program at Military Treatment Facilities (MTFs)
Compliance Plan Implementation Policy
Code of Conduct
Certification Memo
Sample Compliance Committee Charter
TPCP Claim Post-Submission Review Worksheet
MSA Claim Post-Submission Review Worksheet
MAC Claim Post-Submission Review Worksheet
Compliance Audit Checklist
Annual Review of Compliance Program Effectiveness Checklist
Model Compliance Document

15. Changes to Checklist
General Compliance

16. Changes to Checklist, cont.
General Compliance

17. Changes to Checklist, cont.
Internal Management Control
Coding Compliance
Insurance Billing

18. Changes to Checklist, cont.
TPCP
Medicare, Medicaid and Civilian Emergency Patients

19. Changes to Checklist Elective Cosmetic Surgery

20. Changes to Checklist Elective Cosmetic Surgery

21. Changes to TPCP Claim Post Submission Works

22. Checklist Highlights
Is the compliance plan/program reviewed/validated by the UBO Compliance Officer at least annually?
Are audit deficiencies identified by agencies external to the MTF (AAA, DoD IG, etc.) addressed and corrected?
Are the current inpatient ASA rate, Family Member Rate (FMR), Hospital/Professional percentages, Medicare Inpatient Deductible and Food Service (subsistence) rates loaded in CHCS?
Who performs this task?
Who ensures this task was completed and correct?
Do you meet regularly with the Coding Compliance Office?
Is there communication/coordination between the UBO and:
Coding Staff;
Data Quality Manager (or equivalent) on coding issues?

23. Checklist Highlights, cont.
Does the UBO Manager review the monthly DQ statement for information pertinent to the DD Form 2569?
Is there a process to forward insurance information (e.g., DD Form 2569) related to civilian emergencies to the MSA office?
Is a sampling of bills reviewed by someone other than the biller prior to submission to validate accuracy?
Are claims denied due to coding: researched; tracked; appealed?
Are pay-patients alerted to their financial responsibility for healthcare services furnished by the MTF, including pharmacy charges?
How often are unannounced cash counts being conducted?
Are there adequate procedures for accepting and securing funds and valuables into the MTF after normal duty hours?
Is the appropriate patient deposit record form completed for each patient whether or not a deposit is made?

24. Checklist Highlights, cont.
Are civilian emergency patients interviewed, and is an appropriate insurance authorization and release of medical information form signed by the patient?
Are Medicare-eligible civilian emergency patients billed at the appropriate rate?
Is the state Medicaid program billed for emergency, Medicaid-eligible patients?
Is there an MTF process to register designees into CHCS with complete demographic information, if needed, for billing purposes?
Are copies of designee letters maintained on file in the MSA office?
Are there processes to identify/track foreign military accounts and to obtain medical insurance policy information?
Is appropriate documentation (ITOs) being presented to the MSAO prior to treatment?

25. Checklist Highlights, cont.
Are all patients required to pay for their elective cosmetic surgery procedures in advance of the procedures?
Are all patients requesting/receiving elective cosmetic surgery beneficiaries of the MHS?
Is the current version of the cosmetic surgery estimator (CSE) being used IAW issued guidance?
Are all MAC services in the MAC Enhancement Module forwarded to the Legal office for review?
Does your legal authority overseeing medical care recovery instruct you as to which encounters to generate MAC bills for?
Does the UBO furnish claims forms with accurate/correct cost computations to the appropriate office?

26. Billing Risk Areas Using improper DoD billing rates
Outpatient Itemized rates versus inter-agency
Up-coding/unbundling
Changing procedure codes to bill at a higher rate  
Inaccurate evaluation and management codes for a higher intensity or level of care than provided
Charging services without appropriate documentation or substantiation
Billing for services without an established rate
Billing clinic visits as same day surgeries (APVs)
Billing for services not rendered or documented
Billing Medicare for other than civilian emergencies
Accepting overpayments from payers without DHA authorization
Commingling TPC and MSA funds
Destroying claim documentation or accounts receivables
6-year, 3-month statute of limitations

27. Billing Risk Areas, cont.
Failing to execute or follow marginal internal fiscal controls
Separation of duties (e.g., creating & submitting bills, posting, logging, and depositing checks, making entries to financial reports
Reconciling accounting records
Failing to record receivables/checks/payments accurately and promptly
Failing to reconcile financial records
Invoices (DD7/7A), receipts & cash collection vouchers DD Form 1131
Reports of program results DD Form 2570
Daily activity logs
Monthly MSA reports
Inadequate audit trail of financial receipts
Concealing improper billing practices
Impeding investigations
MTF administration overlooking, disregarding, defending, or affirmatively concealing the MTF's illegal billing practices

28. Determining Effectiveness
Policies must be implemented
Achieve desired results
Updated appropriately
Enforced
Messaged from top-down
Culture reflects requirements and standards
Finding problems early before large impact
Decrease in beneficiary complaints
Increased payer reimbursement
Effective resolution of problems – compliance issues not recurring
Data analysis is detecting fraud, waste and abuse

29. Ineffective Compliance Practices
Policies not updated regularly
Governing body does not review/approve
No compliance message from leadership
Contractors, Volunteers, temporary staff, etc. do not receive requirements and standards
Employees unfamiliar with requirements and standards

30. Responding to Alleged Offenses
DoD and Service-specific procedures
Investigate alleged noncompliance, violations of applicable federal laws, or other types of misconduct in accordance with established federal guidelines 
Promptly report offenses to the appropriate authorities in accordance with established Federal guidelines
Send copies of all reports, and subsequent actions taken, to the UBO Service Program Manager

31. Challenges to Making it Work
Program cannot be successful without support of MTF Commander
Keep your leadership informed to keep them engaged
Difficult to get entire MTF to follow the rules
Continual facility training keeps MTFs up to date
Current systems don’t have required capability needed
Maintain a good working rapport with your IT office to ensure your programs get the upgrades they need
Other compliance programs and regulations already audit some areas of the revenue cycle
Work smarter not harder: work with the other areas to collaborate & compile information

32. In Conclusion
Become an expert in billing, coding laws, and policies
Understand best practices for healthcare compliance
Be aware of the billing risk areas in MTFs
Effective ongoing monitoring is necessary (e.g., committee meetings)
Focus organization toward meeting compliance goals – team effort

33. Thank You
Questions?

34. Resources Compliance resources DHA Office of Program Integrity
HHS OIG (model plans)
MTF policies and procedures in addition to DHA UBO toolkit (slide 14)
– Confiscation of Fraudulent Identification (ID) Cards at Military Treatment Facilities
DoDI – Anti-Fraud Program at MTFs
DoDD – Medical Records Retention and Coding at Military Treatment Facilities Care Programs
DoDI – Delivery of Healthcare at Military Treatment Facilities (MTFs)
DoD M – Military Treatment Facility Uniform Business Office (UBO) Manual
DoDD – DoD Privacy Program
DoD R – DoD Privacy Program (Manual)
DoDD – Privacy of Individually Identifiable Health Information in DoD Health Care Programs
DoD R – Privacy of Individually Identifiable Health Information in DoD Health Care Programs (Manual)

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