1. Compliance Program Toolkit
Compliance Training
Welcome to the Compliance Training Presentation presented by PWW Media. PWW Media is a company that specializes in ambulance service compliance solutions, and your agency is using these materials as part of its comprehensive compliance program.

2. Training Overview Federal regulations governing compliance
Documentation compliance
Billing compliance
Compliance program foundation
Your compliance responsibilities
This training presentation will provide you with an overview of important federal regulations governing compliance and the importance of accurate documentation and proper billing in your agency. Next, we will cover the elements that make up the foundation of an effective compliance program and finally, we’ll talk about your compliance responsibilities within your organization.

3. What is Compliance?
Compliance is making certain we conduct ourselves and our operations in accordance with the law
What exactly do we mean when we refer to “compliance”? The simplest definition of compliance means that all of our actions are performed in accordance with the law.

4. Compliance Focus Field personnel Billing personnel
Ensuring complete, accurate and timely documentation
Billing personnel
Coding claims correctly and billing at the appropriate level of service based on accurate and complete patient documentation
Supervisors, managers and executives
Ensuring all operations and business activities are conducted in accordance with the law
Compliance requires a strong focus and a commitment at all levels of your agency. Field providers must ensure complete, accurate and timely patient care documentation; that is the foundation of the organization’s compliance efforts. Billing personnel must ensure that claims are coded correctly and billed at the appropriate level of service based on the accurate and complete patient documentation. And supervisors, managers and executive-level personnel must ensure that all of the organization’s efforts are conducting in compliance with the law.

5. Ambulance Risk Areas Medical necessity Signatures ALS billing Mileage
Facility relationships
Repetitive non-emergency transports
There are several risk areas that have been identified as key for ambulance services. Ensuring that all services billed meet medical necessity requirements is probably the biggest of these. Obtaining the signatures of a patient or authorized representative is another critical areas. Billing at the proper level of service is another, and this is especially important for agencies that bill at the advanced life support level. Accurately documenting and billing transport mileage is important. Properly structuring and pricing contracts and other arrangements with hospitals, nursing facilities and other health care entities is a key compliance areas. And repetitive transports, such as for dialysis patients, has long been identified as posing a particular compliance risk.

6. Federal Regulations
Although there are countless local, state and federal laws that govern EMS and the delivery of ambulance services, there are two primary federal laws that deal with healthcare compliance that affect ambulance services. Those laws are the Federal Anti-Kickback Statute and the Federal False Claims Act.

7. Federal Anti-Kickback Statute (AKS)
Prohibits the knowing and willful offering, payment, solicitation or receipt of any remuneration – that is, money or anything of value – in exchange for the referral of any patient for services that may be paid for in whole or in part by Medicare or any other Federal health care program.
The federal Anti-Kickback Statute - or AKS - prohibits the knowing and willful offering, payment, solicitation or receipt of any remuneration – that is, money or anything of value – in exchange for the referral of any patient for services that may be paid for in whole or in part by Medicare or any other Federal health care program.

8. Federal Anti-Kickback Statute (AKS)
In short, the AKS prohibits “remuneration” (anything of value) in exchange for referrals of Medicare patients
In short, the AKS prohibits “remuneration” which is anything of value in exchange for referrals of Medicare patients.

9. It is a Violation of the AKS to
Offer free or below cost services to a referral source
For example, offering discounts to facilities on the ambulance services for which they are responsible to pay in exchange for referrals of Medicare transports
Let’s go over a few examples of activity that can violate the Anti-Kickback Statute. It is a violation of the AKS to offer free or below cost services to a referral source. For example, offering discounts to facilities on the ambulance services for which they are responsible to pay in exchange for referrals of Medicare transports.

10. It is a Violation of the AKS to
Engage in “swapping”
For example, offering something of value like space or services to a facility below the cost of fair market value in exchange for referrals of Medicare transports
Routinely waive Medicare copayments or deductibles
It is also a violation of the AKS to engage in an arrangement known as “swapping”. Swapping occurs when, for example, an ambulance service offers something of value like space or services to a facility below the cost of fair market value in exchange for referrals of Medicare transports. The routine waiver of Medicare copayments or deductibles can also be an AKS violation, although there are some exceptions for municipal agencies, subscription programs and demonstrated financial hardship.

11. Federal False Claims Act (FCA)
Prohibits knowingly presenting a false or fraudulent claim to Medicare, Medicaid, or other health care programs
“Knowingly” can mean actual knowledge that the claim is false, or it can also mean deliberate ignorance or reckless disregard of the truth of the claim.
The other federal regulation governing compliance is the Federal False Claims Act or FCA. The False Claims Act prohibits knowingly presenting a false or fraudulent claim to Medicare, Medicaid, or other health care programs. Knowingly can mean actual knowledge that the claim is false, or it can also mean deliberate ignorance or reckless disregard of the truth of the claim.

12. It is a Violation of the FCA to
Bill for services or items not actually documented or provided
Submit a claim that does not meet Medicare coverage criteria
Bill for a higher level of service than what was actually provided
Falsify or misrepresent a patient’s condition in documentation
Some examples of violations of the FCA include billing for services or items not actually documented or provided, submitting a claim that doesn’t meet Medicare’s guidelines; billing for a service at a higher level (for instance, billing a BLS claim as ALS) or falsifying or misrepresenting a patient’s condition in your patient care report.

13. It is a Violation of the FCA to
Improperly retain overpayments
The law requires that identified overpayments be refunded to Medicare within 60 days
Failure to do so violates the False Claims Act and can result in significant penalties
It is a FCA violation to improperly retain overpayments. The law requires that all identified overpayments be refunded to Medicare within 60 days. The failure to promptly refund overpayments violates the FCA and can result in significant penalties.

14. AKS and FCA Penalties Criminal penalties Civil penalties
Exclusion from participation in Medicare and Medicaid programs
A violation of the AKS can also constitute a violation of the False Claims Act
Violating the AKS or the FCA can result in a variety of penalties for both individuals and organizations. The penalties can be criminal fines, prison sentences or civil monetary penalties. In addition, a conviction under the FCA or AKS constitutes grounds for exclusion from the Medicare and Medicaid programs. A violation of the AKS can also constitute a violation of the False Claims Act. Keep in mind that these penalties are not mutually exclusive so an individual or agency that violates the AKS may be subject to many or all of these penalties, not just one.

15. Remember Criminal penalties are for criminals
Honest mistakes aren’t crimes
But, overpayments have to be refunded no matter who is at fault
If all of this sounds scary, be comforted by knowing that these criminal penalties only apply to criminals. If you merely make an honest mistake, like inadvertently checking the wrong box on a PCR or using an incorrect code on a claim, those mistakes can be corrected, and those aren’t crimes. But if those mistakes result in your agency receiving reimbursement it wasn’t entitled to, that reimbursement has to be refunded as we discussed earlier.

16. Documentation is Critical to Compliance
Documentation is the foundation of submitting claims, and allowing your organization to get paid for the good work you do. That makes documentation critical to the entire compliance process.

17. Documentation and Compliance
A significant part of any compliance program involves submitting accurate claims
Billing decisions to verify accurate claims are driven by crew documentation
Crew documentation starts at dispatch
The entire process impacts compliance
A significant part of any compliance program involves submitting accurate claims. Billing decisions to verify accurate claim submission are driven by crew documentation which begins at dispatch. The entire process ties together and impacts compliance.

18. Compliant Documentation
All crew and dispatch documentation should
Be thorough and complete
Paint a clear picture of the patient’s physical and medical condition at the time of transport
Provide enough information and cover all the bases necessary for the billing staff to make a proper decision
Be truthful and accurate
To ensure the billing office can make informed decisions, all crew and dispatch documentation should be thorough and complete, and should paint a clear picture of the patient's physical and medical condition at the time of transport. The documentation should provide enough information and cover all the bases necessary for the billing staff to make a proper decision. Most importantly, at all times, patient documentation most always be truthful and accurate.

19. Stay Compliant with Proper Billing
As we just discussed, documentation is the foundation of accurate billing. Proper billing is necessary to maintain compliance.

20. Accurate Coding Upcoding claims is prohibited
Use a billing code that represents a higher level of service than was actually provided
Do not misrepresent the transport destination
For example, submit a claim as though the transport was to a covered destination when in reality the transport was to a non-covered destination (for example a physician’s office)
One important part of proper billing is ensuring the accurate coding of claims. You should never code a claim that is not accurate just so that the claim is paid. It is a violation of the FCA to upcode claims, or, in other words, use a billing code that represents a higher level of service than was actually provided. It is also a violation to misrepresent the transport destination. For example, you should not submit a claim as though the transport was to a covered destination such as a hospital when in reality the transport was to a physician’s office or other non-covered destination just so that you will be paid for the transport.

21. Properly Bill Medicare Beneficiaries
The law prohibits billing Medicare beneficiaries more than the required cost sharing amount
You MAY bill the beneficiary for their deductible and 20% co-insurance
You MAY NOT bill the beneficiary for supplies or other amounts in addition to the Medicare allowed amount
You should always ensure that you properly bill Medicare beneficiaries for only the amounts they are required to pay. The law prohibits billing Medicare beneficiaries for more than the required cost sharing amount. You may bill the beneficiary for their deductible and 20% co-insurance. You may not bill the beneficiary for supplies or any other amount in addition the Medicare allowed amount.

22. Compliant Claim Submission
All claims submitted for payment should
Be supported by documentation
Reflect the services actually provided
Be truthful and accurate
All claims submitted for payment should be supported by the documentation, reflect the services actually provided, and be truthful, and accurate.

23. Compliance Program Foundation
While the FCA and AKS can be complex, the government has given us some insight as to the best way to ensure compliance in our organizations. The Office of Inspector or OIG has outlined the foundation of an effective compliance program in its Compliance Program Guidance Documents.

24. The Compliance “Standards”
The Office of Inspector General (OIG) compliance guideline documents:
Compliance Program Guidance for Ambulance Suppliers
Compliance Program Guidance for Third Party Medical Billing Companies
There are two specific OIG “compliance guidance” documents pertinent to ambulance services – the “Compliance Program Guidance for Ambulance Suppliers” and the “Compliance Program Guidance for Third Party Medical Billing Companies”. Both of these documents outline the seven essential elements of an effective compliance program.

25. 1. Compliance Policies/Procedures
Evaluation and risk analysis
Written standards of conduct
Code of Conduct
Staff must report suspected violations
Adhere to policies and procedures
The first essential element involves the need to establish written policies and procedures, as well as a code of conduct. These policies and procedures address compliance risks within the agency that are identified through a risk analysis. Your agency should also have a Compliance Code of Conduct that requires all staff members to adhere to the compliance policies and procedures and report any suspected violations. The Code of Conduct sets the standards of behavior for all staff members within the agency.

26. 2. Compliance Officer
High level individual who operates and monitors the corporate compliance program
May also designate a Compliance Committee
The second element of the compliance program is a compliance officer. This is a high level individual within the organization who is charged with operating and monitoring the corporate compliance program. In addition to the compliance officer, a compliance committee may be designated so the compliance function is not controlled by a single person.

27. 3. Education and Training
Regular training of all staff members geared to particular job functions
The third element of a compliance program is education and training which should be provided to all staff members regularly and geared towards particular job functions and the associated compliance risks. That’s where this compliance training program comes in!

28. 4. Internal Monitoring/Reviews
Assessment of claims submission process
PCR documentation
Medical necessity
The fourth component necessary to achieve an effective compliance program is internal monitoring, including internal claim reviews to verify the accuracy of claims and identify overpayments. Use of internal reviews helps detect errors, problems and compliance risks for correction.

29. 5. Responding to Misconduct
Ensure that the agency responds appropriately to detected misconduct
The fifth element is responding appropriately to detected misconduct which is typically handled by the compliance officer.

30. 6. Open Lines of Communication
Several communications channels are best
Permits direct communication between compliance officer and all employees
Maintaining open lines of communication and having an “open door policy” is the sixth element outlined by the OIG. Employees should be able to report compliance issues or problems directly to the Compliance Officer, and/or anonymously through , drop-box, or hotlines.

31. 7. Enforcing Disciplinary Standards
Well-publicized disciplinary guidelines
Consistency
The seventh and final compliance program element is enforcing disciplinary standards. Your compliance program should include well-publicized disciplinary guidelines that are enforced consistently.

32. Document Retention Document retention policy
Retain compliance-specific documents
Complaints, investigations and resolutions
Overpayments and refunds
Disputes
Claims and patient care reports
Ensure proper litigation/investigation holds
In addition to the seven elements, the OIG outlines various other standards that should be followed to help assure an effective compliance program. One such requirement is the retention of compliance-specific documents. It is imperative that compliance specific documents, including information about complaints, investigations and resolutions of problems, overpayments, or disputes be maintained along with records of patient care and claims submitted for payment. Your agency should have a document retention policy that ensures the necessary records are kept and that holds are placed on documents that are subject to an investigation or litigation. This means no documents should be destroyed, deleted or altered whenever there is a lawsuit, investigation or audit of any kind.

33. Exclusion Screening
All staff members, vendors, contractors, or anyone affiliated with Federal health care programs will be screened against the OIG’s List of Excluded Individuals and Entities
Additionally, it is imperative to verify that no staff member or volunteer is excluded from participating in the Medicare program prior to hiring or engagement. This can be done online by checking the OIG’s List of Excluded Individuals and Entities.

34. Exclusion Screening
No payment can be made by any Federal health care program for any items or services furnished, ordered or prescribed by an excluded individual or entity
Checking this online exclusions database is critical, because no payment can be made by any Federal health care program for any items or services furnished, ordered or prescribed by an excluded individual or entity. The OIG maintains a searchable database of persons excluded from the Medicare program and every ambulance service and billing agency should periodically check its staff members against this list. The OIG recommends doing this on a monthly basis.

35. Compliance Scenarios
Let’s go through a few scenarios to show how to put your compliance training into action. We’ll give three examples for field providers, billers and agency managers.

36. Scenario 1: Field Provider Compliance
Our first scenario deals with field provider compliance.

37. Scenario 1
When reviewing the PCR after a transport with a paramedic where you drove the ambulance and your partner provided patient care, you notice that your partner documented that the patient was bed confined and carried to the stretcher by two-person sheet lift, even though you saw the patient walk to the stretcher from across the room without assistance. When you ask him about it, he states that he didn’t want to get in trouble for turning in a patient care report that wasn’t billable. What should you do?
Let’s begin with Scenario 1. When reviewing the PCR after a transport with a paramedic where you drove the ambulance and your partner provided patient care, you notice that your partner documented that the patient was bed confined and carried to the stretcher by two-person sheet lift, even though you saw the patient walk to the stretcher from across the room without assistance. When you ask him about it, he states that he didn’t want to get in trouble for turning in a patient care report that wasn’t billable. What should you do?

38. Scenario 1
Misrepresenting the patient’s ambulatory status can affect whether or not the transport was medically necessary
If a claim is submitted to Medicare based on this false documentation, it would a violation of the FCA
It is essential to provide correct and accurate documentation for every transport
If a claim is submitted to Medicare based on this false documentation, it could result in a violation of the Federal False Claims Act. It is essential to provide correct and accurate documentation for every transport. The condition of the patient must always be honestly and accurately documented.

39. Scenario 1
This could result in an overpayment to the agency which would need to be refunded within 60 days of when the overpayment was discovered
If the documentation is submitted and a claim is paid, it would result in an overpayment to the agency which would need to be refunded within 60 days of when the overpayment was discovered

40. Scenario 1
Ask your partner to correct the documentation to accurately reflect the patient’s condition
Do not sign off on PCR that contains inaccurate or false information
Report the issue to your supervisor or the Compliance Officer
In this situation, you should ask your partner to correct the documentation before it is submitted to accurately reflect the patient’s condition as it was observed. You should not sign off on a PCR that contains inaccurate or false information. You should also report the issue to your supervisor or the Compliance Officer.

41. Scenario 2: Manager/Administrator Compliance
Our second scenario deals with manager and administrator compliance.

42. Scenario 2
You are trying to negotiate a contract with a Skilled Nursing Facility to be the primary provider of ambulance service for its residents. The director of the SNF said that if you gave them a 50% discount for the ambulance trips that are the SNF’s responsibility to pay, they would give your agency the contract, which would result in your agency being referred numerous Medicare billable transports. What should you do?
Now let’s try another example. You are trying to negotiate a contract with a Skilled Nursing Facility to be the primary provider of ambulance services for its residents. The director of the SNF said that if you gave them a 50% discount on the services that the SNF has to pay for, they would give your agency the contract. The contract would result in your organization receiving numerous referrals of Medicare patients from that facility. What should you do?

43. Scenario 2 Any below cost services are potential AKS violations
This is referred to as “swapping” discounts for referrals
Giving a discount to a facility in return for their Medicare business is a potential Anti-Kickback Statute violation. The OIG calls this “swapping” and it is a serious compliance violation.

44. Scenario 2
Rates charged to facilities must be at or above the cost of providing the service
The discounted ambulance services to the facility could be seen as an inducement to use the ambulance service for the Medicare-paid ambulance transports. The rates charged to facilities for transports for which they are financially responsible must be at or above the cost of providing the service and should be in line with your Medicare rates.

45. Scenario 2
Refuse to enter a contract with a facility that includes improper discounts
Ask to speak to the facility’s Compliance Officer to work out an arrangement that complies with the AKS
Involve your Compliance Officer in all contractual arrangements to ensure compliance with federal regulations
You should never enter a contract with a facility that includes improper discounts. If you can’t reach an agreement with the Nursing Facility’s director try to speak to their Compliance Officer in order to find an arrangement that works for both parties and complies with the Anti-Kickback Statute. It is wise to involve your agency’s Compliance Officer in all contractual arrangement as well to ensure that your contracts comply with federal regulations.

46. Scenario 3: Biller/Coder Compliance
Our final scenario deals with biller and coder compliance.

47. Scenario 3
While coding claims you read a PCR that lists the destination as Big City Hospital. In the narrative the crew states “patient transported for Dr. appointment”. Big City Hospital is a large campus with several buildings, one of which has physician’s offices. You know that transports to physician’s offices are not typically covered by Medicare, but transports to hospitals are. What should you do?
Now let’s go through our last scenario, this one for billers and coders. While preparing a claim you read a PCR that lists the destination as Big City Hospital. In the narrative the crew states “patient transported for Dr. appointment”. Big City Hospital is a large campus with several buildings, one of which has physician’s offices. You know that transports to physician’s offices are not typically covered by Medicare, but transports to hospitals are. What should you do?

48. Scenario 3
Determine the modifier that appropriately describes the transport destination based on:
Services provided to patient at the destination
How facility is registered and classified with CMS
Licensing of the facility under state law
You should always determine the modifier that appropriately describes the transport destination based on the services that were provided to the patient at the destination; how the facility is registered and classified with CMS; and how the facility is licensed under state law. But, keep in mind, transports to doctor’s offices or professional offices for doctor’s visits aren’t Medicare-covered services.

49. Scenario 3
You may need to get more information from the crew to determine what services the patient received
Doctor “check-up” or
Hospital services performed by a physician
To determine the services provided to the patient at the destination, you may need to obtain more information from the crew. Was the patient transported for a doctor “check-up” or for hospital services that were performed by a physician?

50. Scenario 3
Always code claims to accurately reflect the origin, destination and level of service provided
Check with your supervisor or the Compliance Officer if you have questions
Follow-up with crews if documentation is not sufficient to determine proper billing and coding
You should always code claims to accurately reflect the origin, destination and level of service provided. Check with your supervisor or the Compliance Officer if you have questions. Follow-up with crews if the documentation submitted is not sufficient to determine proper billing and coding.

51. Your Responsibilities
Every individual within the agency has a responsibility to help maintain compliance in all activities and operations.

52. Act Compliantly
Follow the law, the Code of Conduct, and all compliance policies
Promptly report compliance concerns to the Compliance Officer or your supervisor
Anonymous reports can be made
All questions and concerns will be investigated and handled appropriately
It is your responsibility to follow the law, the Code of Conduct and all compliance policies. Promptly report concerns to the Compliance Officer or your supervisor. You may also choose to report your concerns anonymously. All questions and concerns will be investigated and handled appropriately.

53. No Retaliation for Good Faith Reporting
Staff members are expected and encouraged to report any compliance concerns
There will be no retaliation or any adverse action against any staff member who in good faith makes a report of a compliance concern
Staff members are expected and encouraged to report any compliance concerns. There will be no retaliation or any adverse action against any staff member who in good faith makes a report of a compliance concern.

54. Remember
Always check with your Compliance Officer regarding your agency’s policies and procedures and Compliance Program
Never hesitate to express your compliance concerns! The compliance officer can help you do that, directly or through our anonymous reporting process
Remember, every agency is different, so always check with your Compliance Officer regarding your agency’s policies and procedures and Compliance Program. Never hesitate to express your compliance concerns! The compliance officer can help you do that, directly or through our anonymous reporting process.

55. For more compliance solutions visit
This concludes the Compliance Training provided by PWW Media, Inc. Thank you for your participation. For more compliance solutions visit pwwmedia.com.