Operationalizing “Compliance”

Anthony Guerrero, M.D.Anthony Guerrero, M.D.

Associate Professor of Psychiatry and PediatricsAssociate Professor of Psychiatry and Pediatrics

Vice-Chair for Education and Training, PsychiatryVice-Chair for Education and Training, Psychiatry

Objectives

To give a practical overview of things commonly To give a practical overview of things commonly associated with regulatory “compliance”: billing associated with regulatory “compliance”: billing and coding compliance, STARK, EMTALA, and coding compliance, STARK, EMTALA, perhaps other fancy acronyms.perhaps other fancy acronyms.

To outline basic resources and generic steps in To outline basic resources and generic steps in creating a voluntary compliance program.creating a voluntary compliance program.

Assumption: basic orientation to compliance Assumption: basic orientation to compliance relevant to residency training; this presentation relevant to residency training; this presentation will focus on what you may need to expect after will focus on what you may need to expect after residency.residency.

Personal message

We want you to be successful in whatever We want you to be successful in whatever practice you choose.practice you choose.

We want to help you stay out of unintended We want to help you stay out of unintended trouble.trouble.

We want you to feel comfortable taking We want you to feel comfortable taking care of public-sector patients and patients care of public-sector patients and patients on governmentally sponsored insurance on governmentally sponsored insurance plans.plans.

Say what? Let’s play “matching”:

1.1. Billing and coding Billing and coding compliancecompliance

2.2. HIPAAHIPAA

3.3. STARKSTARK

4.4. EMTALAEMTALA

5.5. CFR 42CFR 42

A.A. Relates to assessment and Relates to assessment and stabilization of patientsstabilization of patients

B.B. Relates to privacyRelates to privacyC.C. Relates to substance abuse Relates to substance abuse

treatment treatment D.D. Relates to accurate Relates to accurate

documentation and documentation and preventing preventing erroneous/fraudulent erroneous/fraudulent claimsclaims

E.E. Relates to anti-kickback Relates to anti-kickback rulesrules

Answers: 1. D. 2. B. 3. E. 4. A. 5. C.

Case Scenarios

In preparation for private practice, which In preparation for private practice, which you plan to start right after graduation, you you plan to start right after graduation, you run through a checklist of all the things you run through a checklist of all the things you need to take care of. Did you make sure to need to take care of. Did you make sure to include things like “compliance” and include things like “compliance” and “HIPAA?”“HIPAA?”

Case Scenarios

You are interviewed for an appealing job at You are interviewed for an appealing job at an agency that recently came under a an agency that recently came under a “corporate integrity agreement.” You “corporate integrity agreement.” You wonder what this means, and what the wonder what this means, and what the implications are for your practice with implications are for your practice with them.them.

Why should I bother?

Can anyone tell me?Can anyone tell me?

Remember that quality is the driver of patient care processes Nearly every other industry – e.g., airline Nearly every other industry – e.g., airline

industry, etc. – has rules to follow.industry, etc. – has rules to follow. Error reductionError reduction is a key principle: reduces is a key principle: reduces

waste, improves qualitywaste, improves quality

Individual/small group practices

Let’s start off with the DHHS/OIG guidelines for Let’s start off with the DHHS/OIG guidelines for compliance programs… compliance programs…

http://oig.hhs.gov/authorities/docs/physician.pdfhttp://oig.hhs.gov/authorities/docs/physician.pdf Probably one of the most important websites Probably one of the most important websites

you’ll ever encounter!you’ll ever encounter! Wonderful examples of fraud, and everything Wonderful examples of fraud, and everything

you’d ever want to know about penalties!you’d ever want to know about penalties! A voluntary compliance program is MUCH better A voluntary compliance program is MUCH better

than an involuntary onethan an involuntary one

Main principles

Claims submitted to federal health care Claims submitted to federal health care programsprograms

Private payor claims may also be covered Private payor claims may also be covered by a compliance planby a compliance plan

Main principles

Internal monitoring and auditingInternal monitoring and auditing Written standards and proceduresWritten standards and procedures Compliance officer or contactsCompliance officer or contacts Training and educationTraining and education Responding appropriately to possible violationsResponding appropriately to possible violations Open lines of communication for education and Open lines of communication for education and

monitoringmonitoring Well-publicized disciplinary standardsWell-publicized disciplinary standards

Component 1: Internal monitoring and auditing Accurate billing and coding Accurate billing and coding Accurate documentationAccurate documentation

Consider templatesConsider templates Know your referencesKnow your references

Reasonable-ness and necessity of servicesReasonable-ness and necessity of services Absence of incentives for unnecessary Absence of incentives for unnecessary

servicesservices

Component 1: Internal monitoring and auditing The OIG recommends that claims/services that The OIG recommends that claims/services that

were submitted and paid during the initial three were submitted and paid during the initial three months after the education and training program months after the education and training program be examinedbe examined

Periodic audits should be conducted at least once Periodic audits should be conducted at least once per yearper year

5+ medical records per federal payor; 5-10 per 5+ medical records per federal payor; 5-10 per physicianphysician

Action plan (e.g., repayment, correction of Action plan (e.g., repayment, correction of processes, training, etc.) for problems uncoveredprocesses, training, etc.) for problems uncovered

Quick quiz: can anyone define for me… 9080190801 9080590805 9080790807 9084690846 9084790847 9086290862

Quick quiz:

How exactly do insurance companies know How exactly do insurance companies know what services you provided and for what?what services you provided and for what?

What pieces of information do they need to What pieces of information do they need to know, and how do they get that know, and how do they get that information?information?

Component 2: Standards and Procedures Keep these in a binder!Keep these in a binder! Having policies and procedures will save you!Having policies and procedures will save you! Can cross-reference AMA ethics guidelinesCan cross-reference AMA ethics guidelines ““Risk areas” to cover:Risk areas” to cover:

Coding and billingCoding and billing Reasonable and necessary servicesReasonable and necessary services Documentation (including reasons for services, Documentation (including reasons for services,

location of services)location of services) Improper inducements, kickbacks, and self-referralsImproper inducements, kickbacks, and self-referrals

Practical examples

If I saw a patient for 2 hours of psychotherapy (I If I saw a patient for 2 hours of psychotherapy (I couldn’t help it, they kept talking), can I bill them for couldn’t help it, they kept talking), can I bill them for 2 visits on 2 separate days, since I did the work?2 visits on 2 separate days, since I did the work?

If I spent 30 minutes talking to a patient over the If I spent 30 minutes talking to a patient over the phone (once again, I couldn’t help it), and then phone (once again, I couldn’t help it), and then calling in a prescription to the pharmacy, can I bill for calling in a prescription to the pharmacy, can I bill for a medication management or psychotherapy visit?a medication management or psychotherapy visit?

Can I waive someone’s co-pay? They’re having a Can I waive someone’s co-pay? They’re having a difficult time right now and under a lot of emotional difficult time right now and under a lot of emotional distress.distress.

Practical examples

I’m interested in a primary care liaison I’m interested in a primary care liaison model. A group of internists wants to lease model. A group of internists wants to lease me office space at a good rate. Is there me office space at a good rate. Is there anything I need to be careful of?anything I need to be careful of?

I’m a combined primary care/psychiatry I’m a combined primary care/psychiatry graduate. Can I have a combined primary graduate. Can I have a combined primary care/psychiatry practice and refer patients to care/psychiatry practice and refer patients to myself?myself?

Practical examples

I’m planning to work in a public-sector clinic I’m planning to work in a public-sector clinic where senior residents rotate. I was told that I where senior residents rotate. I was told that I only need to sign their notes. Is that true? only need to sign their notes. Is that true?

I’m on-call for the psychiatry ED service. What I’m on-call for the psychiatry ED service. What does this mean in terms of whom I am obligated to does this mean in terms of whom I am obligated to treat?treat?

I’m interested in making a lot of money. What do I’m interested in making a lot of money. What do I need to be careful of if I start a “walk in” I need to be careful of if I start a “walk in” psychiatry clinic?psychiatry clinic?

Component 3: Compliance Officer Overseeing implementation and insuring the Overseeing implementation and insuring the

up-to-dated-ness of the compliance programup-to-dated-ness of the compliance program Coordinating periodic auditsCoordinating periodic audits Coordinating trainingCoordinating training Checking OIG’s black-listChecking OIG’s black-list Investigating problems and insuring Investigating problems and insuring

corrective actioncorrective action

Component 4: Training and Education Compliance in general: rules and penaltiesCompliance in general: rules and penalties Coding and billingCoding and billing

CPTCPT ICD-9ICD-9

Should have at least annual trainingShould have at least annual training Document any training activity; remember Document any training activity; remember

your binder!your binder!

Component 5: Responding to possible violations Overpayment issuesOverpayment issues Individual correctionIndividual correction Systems correctionSystems correction Possibility of criminal violationsPossibility of criminal violations Know your resourcesKnow your resources

Component 6: Open lines of communication People shouldn’t be intimidated from doing People shouldn’t be intimidated from doing

what’s necessary to insure regulatory what’s necessary to insure regulatory compliancecompliance

Exchange of informationExchange of information

Component 7: Disciplinary standards Should be a part of initial and ongoing Should be a part of initial and ongoing

orientationorientation Main theme is accountabilityMain theme is accountability

Generic steps that could benefit any patient care process Key ingredients:Key ingredients:

Sound philosophy (quality, efficiency)Sound philosophy (quality, efficiency) Policies and proceduresPolicies and procedures Forms to insure that things are done uniformly and Forms to insure that things are done uniformly and

painlesslypainlessly Quality improvement principles (plan, do, check, act; Quality improvement principles (plan, do, check, act;

monitoring and correction; mechanism to continuously monitoring and correction; mechanism to continuously update)update)

Administrative structure; peopleAdministrative structure; people Education and training and accountabilityEducation and training and accountability

Ever wonder how the airline industry does it?Ever wonder how the airline industry does it?

Similar processes with HIPAA compliance Policies and procedures, based on HIPAA laws, Policies and procedures, based on HIPAA laws,

for anything involved in transaction of for anything involved in transaction of informationinformation

Forms (privacy practices, consent forms) to insure Forms (privacy practices, consent forms) to insure that things are done uniformly and painlesslythat things are done uniformly and painlessly

Quality improvement principles (plan, do, check, Quality improvement principles (plan, do, check, act; monitoring and correction; mechanism to act; monitoring and correction; mechanism to continuously update)continuously update)

Administrative structure; people (privacy officer)Administrative structure; people (privacy officer) Education and training and accountabilityEducation and training and accountability

Relevant to psychiatry

Can refer to frequently asked questions Can refer to frequently asked questions about HIPAA:about HIPAA:http://www.hhs.gov/ocr/hipaa/http://www.hhs.gov/ocr/hipaa/

CFR 42 is very important!CFR 42 is very important! PART 2--CONFIDENTIALITY OF PART 2--CONFIDENTIALITY OF

ALCOHOL AND DRUG ABUSE PATIENT ALCOHOL AND DRUG ABUSE PATIENT RECORDS:RECORDS:

http://www.access.gpo.gov/nara/cfr/waisidx_03/42cfr2_03.htmlhttp://www.access.gpo.gov/nara/cfr/waisidx_03/42cfr2_03.html

Technology: the wave of the future Computerized, customizable packages for Computerized, customizable packages for

HIPAA complianceHIPAA compliance Useful websites are posted on our very own Useful websites are posted on our very own

DOP website:DOP website:

http://dop.hawaii.eduhttp://dop.hawaii.edu

Thank you for your attention!Good luck!

Anthony Guerrero, M.D.Anthony Guerrero, M.D.

GuerreroA@dop.hawaii.eduGuerreroA@dop.hawaii.edu