New Provider Compliance TrainingShepherd Center

Course Curriculum

• Introduction to Compliance• Documentation • Conflicts of Interest• Fraud & Abuse Laws• Audits• Patient Rights

What is Compliance

Regulatory compliance describes the goal that Shepherd Center aspires to in our

efforts to ensure that personnel are aware of and take steps to comply with relevant

laws and regulations.

Why is it Important

In simple terms, it has the potential to positively impact our organization’s clinical

care and revenue. The purpose of our compliance program is to ensure that we

adhere to the laws and regulations set forth by Medicare/Medicaid and other entities, all in an

effort to avoid the imposition of fines and/or penalties by them for any reason.

DocumentationWe remain compliant via proper

documentation.

Documentation is the key driver for our

hospital processes and for reflecting quality of

patient care.

If it’s not documented, it wasn’t done!

Inappropriate documentation affects the ability

to bill and collect appropriate reimbursement;

to appeal denials; to justify admission and

continued length of stay; to project quality and

to comply with regulatory requirements.

Appropriate Documentation Will Yield:

o Improved overall quality of care

o More accurate hospital / physician profiling

o More detailed patient clinical database

o More timely billing process

o Reduction of potential denials

o Reduced compliance risk

o Improved case mix index

o More appropriate payments from DRG-based payers

When does a conflict exist?

When your personal interests oractivities may influence your judgment in the performance ofyour job duties.

Conflicts of Interest

•Accepting gifts from vendors

•Using your employer’s facilities for financial gain

•Participating in activities that violate or might reasonablybe perceived to violate any of the principles governingresearch

Fraud & Abuse – False Claims Act (FCA)

“Knowingly

includes acting in reckless disregard of the truth or falsityof the information presented

Applies to “any person” who “knowinglypresents or causes to be presented” to

the “United States Government” a “falseor fraudulent claim for payment.”

Note:No proof of specific intent

to defraud is required

Fraud & Abuse – Stark LawSelf-referral provision enacted in 1989

Stark I – became effective January 1, 1992

Prohibits a physician from referringpatients to a clinical laboratory inwhich the physician or a member ofhis or her immediatefamilyhas afinancial relationship

Stark II – became effective January 1, 1995

Expands the referral prohibitions to includenot only clinical laboratorybut alsoDesignated HealthServices (DHS)

Physical Therapy, occupation therapy,and speech- language pathologyservices

Radiation therapy services and supplies

Parenteral and enteral nutrients,equipment, and supplies

Inpatient and outpatient hospitalservices

• Prosthetics, orthotics, and prostheticdevices and supplies

Radiology and certain other imagingservices

Durable medical equipmentandsupplies

Outpatient prescription drugs

Home health services

Knowingand willful offer,

payment,solicitation,or receipt of

remunerationto induce

(or in return for)the referral ofFederal healthcare program

business

OIG may seek up to $25,000 and imprisonment up to 5 years foreach act (offer, payment, solicitationor receipt of remuneration),an assessment of up to three times the amount of the improper

remuneration (without regard for whether a portion of theremuneration was for lawful purposes), and exclusion

Fraud & Abuse –Anti-Kickback Statute (AKS)

Audits - Why Audit

Medical auditing is a key step in the compliance process. Shepherd Center’s medical

audit focuses on many areas of practice; ensuring medical necessity, correct coding and

compliance with applicable regulatory requirements.

Payers may require reasonable documentation that services are consistent with the

insurance coverage provided in order to validate items such as:

• The site of service

• The medical necessity and appropriateness of the diagnostic

and/or therapeutic services provided: and/or

• That services furnished have been accurately reported.

Chart Audits… Making it Count

The following principles should be followed in an effort to attain a passing score on a chart audit:

1. The medical record should be accurate, complete, timely and legible.

2. The documentation of each patient encounter should include:

• Reason for the encounter and relevant history, physical examination findings and prior diagnostic test

results.

• Assessment, clinical impression, or diagnosis.

• Medical plan of care.

• Date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or consulting physician.

5. Appropriate health risks factors should be identified.

6. The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The CPT and ICD-10 codes reported on the health insurance claim form or billing statement should be supported

by the documentation in the medical record.

Patient Rights - Treatment

The patient has the right to considerate

and respectful treatment and services

in a secure and safe environment.

This includes the right to appropriate

services including pastoral care and

support for spiritual and cultural

beliefs and access to protective

services.

Patient Rights - Information & Medical Records

• The patient has the right to accurate and understandable

information concerning his/her diagnosis, treatment and

prognosis.

• Patients are encouraged to ask physicians, caregivers, and

therapists questions and have the right to give feedback about

his/her care.

• Patients are advised of their right to make an informed choice.

• Patients have the right to know the identity and qualifications of

all staff involved in their care.

• The patient has the right to review the records and any

communication of information pertaining to his/her care and to

have the information explained or interpreted as necessary,

except when restricted by law.

Patient Rights - Consent

The patient has the right to have a reasonably informed

participation in decisions involving their health care. To the

degree possible, this should be based on a clear, concise

explanation of the patient’s condition and of all proposed

technical procedures, including the possibilities of any risk

of mortality or serious side effects, problems related to

recuperation, and probability of success.

The patient should not be subjected to any procedure

without the patient's voluntary, competent, and

understanding consent or the consent of the patient's legally

authorized representative. Where medically significant

alternatives for care of treatment exist, the patient shall be

so informed.

Patient Rights - Confidentiality

The patient has the right to every consideration of privacy.

Any discussions, consultations, examinations, and treatments

should be conducted to protect each patient's privacy.

The patient has the right to expect that all communications and

records pertaining to his/her care will be treated as confidential.

CONGRATULATIONS

You have completed the

New Provider Compliance Training Course

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