#ZOLLSummit

This Session is CEU Approved

http://www.surveymonkey.com/s/NAAC_Certs

Compliance…That’s Your Job!

Presented by:

Renee Collier Implementation Specialist

ZOLL

Compliance

1 a: the act or process of complying to a desire, demand, proposal, or regimen or to coercion

b: conformity in fulfilling official requirements 2 : a disposition to yield to others 3: the ability of an object to yield elastically

when a force is applied : flexibility

OIG Most Wanted

Compliance in Ambulance Billing

Who’s responsible?

Management

Compliance in Ambulance Billing

Who’s responsible?

Field Crews

Compliance in Ambulance Billing

Who’s responsible?

Coders/Billers

Objectives

Review OIG’s Ambulance Service Compliance Program Guidelines

Review Self Audit Protocol

The Plan

Federal Register/Vol.68, No.56 OIG Voluntary Program Guidance

- Mandatory in 2014 Guidelines – Not A One Size Fits All Highly Recommended

Document Overview

Produced June 2002 Outlines most common issues of fraud and

abuse. Basically looks to:

Identify

Prevent

Correct

Areas of Concern

Inappropriate Transports Medically Unnecessary Transports Falsifying Trips Misrepresenting Destination Facility False Documentation Billing singly for group transport. Up-coding Payment of Kickbacks

What You Need

Policies and Procedures Compliance Officer Education & Training Programs Internal Reviews Response to Misconduct Communication Know what works for your organization

- Tailor the plan for your specific risks/needs.

Policies 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.

Compliance Officer

Should be a management position Should not be subordinate to General Counsel

or Chief Financial Officer Oversees day-to-day compliance activities. Implement a Compliance Committee to assist

in developing a Compliance Program

Training and Education

Organizational and Job Specific

Employees 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.

Training 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.

Training 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.

Claims 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?

Claims 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.

Claims 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.

Claims Submission

Use baseline audit to develop benchmarks.

Use external benchmarks as well.

Document audit dates and outcomes.

Use outcomes to drive training.

Pre-Billing Review

Look for appropriate documentation. Pre-Bill? Medical Necessity Narrative Coded Correctly If not complete, do not submit the claim! You SHOULD be doing this with every claim!

Paid Claims Review

Under/Overpayments

An overpayment is one that has been received in excess amounts due and payable under Medicare statute and regulations.

Paid 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.

Claims 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.

Denials in RescueNet

System 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.

Sanctioned Suppliers

It is your responsibility to check the websites for excluded individuals either in your employ or possibly going to be.

http://oig.hhs.gov http://www.arnet.gov/epls

Identification 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 http://oig.hhs.gov

Response to Risks

Develop written response protocols.

Address issues in a timely manner.

Document, document, document!

Specific Fraud and Abuse Risks

Medical Necessity Varies 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.

Upcoding

Charging ALS service charge for a BLS call.

Charging for services not rendered.

Non-Emergency Transports

High Risk for fraud and abuse Must meet Medical Necessity Always document accurately whether or not

you believe Medicare will pay. Ensure crews document patient condition

accurately. Acronyms in Documentation

EMS Acronyms

DRT- Dead Right There FTD- Fixing to Die CTD – Circling the Drain DDPI – Death Despite Paramedic Interference HIBGIA- Had it Before, Got it Again FDSD – Found Dead, Stayed Dead PEP – Pharmaceutically Enhanced Personality ID-10-T on Scene

Scheduled/Unscheduled Transports

Obtain PCS Routine Doctor/Dialysis More appropriate transport available Do NOT submit inappropriate claims to

Medicare.

Documentation, Billing & Reporting

Inadequate/Faulty Documentation = High Risk

Dispatch Transport Personnel Coders/Billers

Minimum Information

Dispatch instructions Why Ambulance transport was needed Level of Service required Patient Status Trip Ordered by? Trip Times: Dispatch, Arrival and Destination Mileage Pickup/Destination Codes/HCPCS Services provided/Loaded Miles

Coordination 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?

Part A

Part A Agreements Contractual Agreements

Not billable to Medicare

High risk to violate Anti-Kickback Statute

Medicaid Individual to each state

States that receive Medicaid funds must provide transportation to recipients to and from Medical appointments.

Federal regulations define medical transportation and describe reimbursable costs.

Kickbacks and Inducements

Be familiar with Safe Harbor regulations Referral Sources Municipal Contracts Ambulance Restocking Mutual Aid Agencies Hospitals and SNF’s

Additional Risks

No transport Multiple Patient Multiple Agency Response Billing In Excess

Discovery

Any issues discovered that could be a potential criminal, civil or administrative violation may be disclosed to the OIG

Provider Self Disclosure Protocol

- Federal Register/Vol. 63, No. 210 RAT-STATS

Self Disclosure

Provider Self Disclosure Protocol Voluntary Must be willing to “police” your own agency Correct underlying problems Work with government to reach resolution

Knowledge 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

Sources

http://www.merriam-webster.com/dictionary/compliance

https://www.cms.gov/MLNProducts/downloads/OverpaymentBrochure508-09.pdf

http://oig.hhs.gov/compliance/101/index.asp

Section 1862(b)(6) of the Act (42 U.S.C. 1395y(b)(6))

www.cms.hhs.gov/medlearn/cbts.asp

https://www.cms.gov/MedicareContractingReform/Downloads/compliance.pdf

Sources

http://www.brainyquote.com/quotes/topics/topic_government2.html#B0ToaumFt9PHO4x2.99