Willow Creek Physician Office

By: Andrea Anselme & Carly Bethea

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Mission Statement:

Willow Creek Physician Office strives to be a leader in the excellence of patient centered care by

providing compassionate lifelong services with health professionals you can trust. Patient care is

our passion, and it is a privilege to serve our community.

Vision Statement:

Our goal for the patients experience is to deliver quality satisfactory health care that we would

expect for our own family. We hope that through our devoted care and teamwork we improve the

lives of those we serve.

We Value:

Integrity

Well-being

Teamwork

Devotion

Trust

Quality care

Knowledge

Patient-Physician Relationships

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Code of Ethical Conduct

Willow Creek’s Code of Ethical Conduct ensures that we are honoring our mission, vision, and

value statements. These ethics reflect the behavior of our staff in all situations.

Ethical Principles:

I. Law-abiding: We use current processes that are compliant with the HIPAA

Privacy Rule. The security of our patients’ medical information is of our upmost

concern.

II. Compassion: Willow Creek’s faculty and staff have a passion for patient care. We

have empathy for all of our patients and their needs.

III. Diversity: We treat all patients equally regardless of race, ethnicity, religion, or

gender. To the best of our ability, we assist customers with communication

barriers.

IV. Excellence: Our faculty and staff are dedicated to providing excellence in care by

treating patients with compassion and dignity.

V. Honesty: Patients can put their trust in Willow Creek’s character and values for

all of their healthcare needs. We always focus on the best interests of our patients

by maintaining honesty and gaining trust through patient relationships.

VI. Commitment: Our physicians are devoted to expanding their medical knowledge

to provide the best information and care for their patients.

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Code of Conduct Form

I,___________________________________, have fully read and understand Willow

Creek’s Code of Ethical Conduct. I accept the terms and acknowledge that they must be

followed as long as I am employed by this company.

____________________________ ___________________

Employee Signature Date

___________________________ ____________________

Supervisor Signature Date

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Compliance Officer Duties

1. Preferred Credential: Certified Medical Compliance Officer (CMCO)

2. Oversee corporate compliance program

3. Develop and implement policies and procedures

4. Evaluate areas of a risk and inform departments of corrective action plan

5. Create and enforce compliance training program

6. Educate other departments on compliance issues

7. Monitor and supervise compliance activities

8. Promote and lead compliance committee meetings

9. Communicate Standards of Conduct

10. Authorize management of the Compliance Hotline

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Compliance Officer

Mary Anderson, Ph.D., MS, RHIA, CMCO Willow Creek Physician Office Compliance Officer

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Compliance Committee Duties

1. Have general knowledge about compliance and quality issues within Willow Creek

Physician Office.

2. Attend quarterly meetings to monitor progress and effectiveness of compliance plan.

3. Recommend improvements for areas lacking in compliance and make necessary

changes.

4. Ensure consistent communication throughout the office by educating staff on

compliance issues, improvements, and clarifications.

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Compliance Committee Members

Henry Johnson, RHIA Health Information Manager

Megan Phillips, FNP-BC Family Nurse Practitioner

Sarah Young, JD Healthcare Attorney

Jeff Clark , MD Family Physician

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Risk Areas

1. Billing

a. Billing for items or services not rendered or provided as claimed

b. Submitting claims for equipment, medical supplies, and services that are not

reasonable and necessary

c. Double billing resulting in duplicate payment

d. Billing for non-covered services as if covered

e. Knowing misuse of provider identification numbers which results in improper billing

2. Coding

a. Unbundling (billing for each component of the service instead of billing or using an

all-inclusive code)

b. Failure to properly use coding modifiers

c. Clustering

d. Up coding the level of service provided

e. Under coding

f. Limited knowledge of coding rules and coding clinics

3. Documentation

a. Untimely

b. Inaccurate, incomplete, and illegible

c. CPT and ICD-9 CM codes not used for claim submission or supported by

documentation and the medical record

d. Inappropriate completion of HCFA 1500 form

4. Improper Inducements, Kickbacks, Self-Referrals

a. Financial arrangement with outside entities to whom the practice may refer federal

healthcare program business

b. Joint ventures with entities supplying goods or services to the physician practice or its

patients

c. Soliciting

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Policies & Procedures

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Billing

Policy

Willow Creek Physician Office should follow all federal regulations regarding billing by

ensuring: that billed items and services are rendered to the patient, all claims are

reasonable and necessary, billing is not duplicated or for non-covered services, and no

misuse of provider identification numbers. Quarterly reviews will be completed to

guarantee compliance with our policy. All billing is required to be accurate and truthful;

no staff member should ever misrepresent charges on behalf of third party payors.

Procedure

I. Prevention of Billing Items and Services not Provided to Patients

a. Evaluate patient charts for correct source of payment.

b. Ensure accuracy of billed services that pertain to documented patient visit.

c. Communication with other personnel within the office for clarification.

II. Prevention of Claims that are not Reasonable and Necessary

a. Educate staff and ensure understanding of Federal False Claims Act.

b. Using a computer system to identify false claims before billing.

c. Internal and External monitoring for uncertain billing behaviors.

III. Prevention of Billing that is Duplicated or for Non-Covered Services

a. Ensure each patient is only assigned one identification number.

b. Confirm accuracy of itemized bill for duplication errors before administering

to patient.

c. Check coverage and ask questions before services are rendered.

i. Understand patient benefits before admission.

ii. Patients with non-coverage of services should have their options explained

in addition to secondary reimbursement plan.

IV. Prevention of Misuse of Provider Identification Numbers

a. Avoid revealing identification number and password to other staff members.

b. Log out of all computer systems before leaving computer station unattended.

c. Refrain from asking other personnel to complete work under identification

number.

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Coding

Policy

Willow Creek Physician Office complies with the federal regulations as well as the

following standards: bundling billing components, proper use of coding modifiers,

prevention of clustering and up coding, and abiding by coding regulations. Employees

will maintain a high level of professionalism and ethical behaviors while performing

these procedures. Adherence to these guidelines is essential.

Procedure

I. Prevention of Unbundling Billing Components

a. Outsourcing staff to review and audit charts for unbundling.

b. Proper education and training for coders on how to bundle multiple

components under a single fee.

c. Coders must use all-inclusive codes when necessary.

II. Proper use of Coding Modifiers

a. Coders must reference sections of the Medicare Provider Manual to ensure

appropriate use of modifiers.

b. Consult National Correct Coding Initiative (NCCI) for coding modifier

clarification.

c. Remain updated on NCCI coding edits.

III. Prevention of Clustering and Up Coding

a. Monitoring and proper use of the encoder.

b. Abiding by the laws set by CMS regarding clustering and up coding.

c. Audit claims monthly to ensure services and procedures rendered align with

what was coded.

IV. Abide by Coding Regulations

a. Following rules and guidelines in coding clinics.

b. Coders must have a background of clinical knowledge in pathophysiology and

anatomy & physiology.

c. Reference coding materials when questions arise and apply concepts

accordingly.

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Documentation

Policy

Willow Creek Physician Office should guarantee timely, accurate, and complete documentation

to improve the quality of clinical patient care. Documentation should comply with the Federal

Register. Proper documentation habits are necessary to receive full reimbursement from the third

party payor.

Procedure

I. Prevention of untimely documentation

a. Perform concurrent patient documentation.

i. Documented and completed during patient encounter

b. Provide physicians with incentives to complete documentation in a timely

manner.

c. Ensure that physicians reference The Documentation Guidelines for Evaluation

and Management Services.

II. Prevention of incomplete, inaccurate, and illegible documentation

a. Documentation of each patient encounter must include:

Reason for encounter

Any relevant history

Physical examination findings

Prior diagnostic test results

Assessment, clinical impression, diagnosis

Plan of care

Date and legible identity of the observer

b. Facilitating high quality patient care by properly documenting and verifying

what services were actually provided validates:

i. Site of the service

ii. Appropriateness of the services provided

iii. Accuracy of billing

iv. Identity of the caregiver

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c. Randomized audits by various selected staff member to ensure legibility of

physician documentation.

III. Ensure CPT and ICD-9 CM codes are used for claim submissions and are supported

by documentation and the medical record

a. The medical record chart must contain all necessary information reported on

the health insurance claims form.

b. Caregiver of service must be clear within the documentation.

c. Compare denial rates with other practices within the same specialty to identify

variances.

IV. Appropriate use of the HCFA 1500 form

a. Coders must link the diagnose code with reason for visit or service.

b. Ensure appropriate use of modifiers.

c. Under Medicare Secondary Payor policy, provider must inform Medicare about

beneficiaries other than insurance coverage if practice is aware.

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Improper Inducements, Kickbacks, and Self-

Referrals

Policy

Willow Creek Physician Office is committed to maintaining high ethical standards and ensuring

that physicians are complying with all applicable laws pertaining to the Anti-Kickback law. This

federal law prohibits healthcare providers and suppliers from soliciting, offering, paying, or

receiving prohibited remuneration. Our facility interacts with several physicians to provide high

quality care to our patients through adhering to this law.

Procedure

I. Prevention of inducements, kickbacks, self-referrals, and soliciting

a. To avoid inappropriate inducements to patients, our physician practice will obtain

and become familiar with the OIG special fraud alerts and advisory opinions.

b. If an employee is concerned with suspicious behavior regarding inducements,

kickbacks, or self-referrals, the Chief Compliance Officer must be contacted.

c. Gift giving must be monitored by the Chief Compliance Office to ensure

inducements do not influence business decisions.

II. Prevention of financial arrangements with outside entities and joint ventures entities

supplying goods or services

a. Physicians must not pay unreasonable or excessive compensation for goods and

services.

b. Any business arrangements must be reviewed by legal counsel familiar with the

Anti-Kickback Statute.

c. Business arrangements within Willow Creek Physician Office to an outside entity

will be in a fair market value basis.

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Compliance Education and Training

Education:

Willow Creek Physician Office staff is required to attend quarterly in-person training sessions on

site to ensure necessary education is communicated effectively. After education sessions,

employees will have a better understanding of topics covered which include:

Job analysis of specific duties pertaining to job title

Availability of online resources

Technical support for unexpected occurrences or concerns

Awareness of upcoming changes

Information about future CE events

CMS newsletters

Training:

1. Four training seminars will be offered throughout the year at an outside facility. All new

and current employees must attend one of the training seminars annually. Information

covered will include:

Risk Area

Core Values

Staff Compliance

Quality Improvement

Patient Service Improvements

2. An officer of our compliance committee will present a seminar that includes an

interactive Power Point presentation followed by group activities.

3. When the seminar has ended, employees are required to take an assessment regarding

information that was covered to ensure retention of information.

Employees must score the assessment with a 90% or above to pass.

If employee does not pass the assessment within the first try, a second attempt is

allowed.

Failure to pass the second attempt, will require employee to attend another

seminar. Once the assessment is passed, the Training Completion Form must be

filled out to file with employee records.

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Training Completion Form:

I, _______________________________, have completed Willow Creek Physician Office

Training Seminar and:

Passed the training assessment

Understand the annual requirement attendance for each year of employment

Understand the quarterly requirement attendance for education sessions for the

duration of employment

________________________________________ __________________

Employee Signature Date

________________________________________ __________________

Compliance Officer Signature Date

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Compliance Hotline

The following compliance committee members may be contacted for any questions or

clarifications regarding our facility’s compliance plan:

Henry Johnson, RHIA Health Information Manager

HJohnson@WillowCreek.com

Office: (309) 233-2399

Cell: (309) 867-5309

Fax: (309) 998-1121

Megan Phillips, FNP-BC Family Nurse Practitioner

MPhillips@WillowCreek.com

Office: (309) 765-0234

Cell: (309) 897-4562

Office: (309) 550-4312

Sarah Young, JD Healthcare Attorney

SYoung@WillowCreek.com

Office: (309) 878-0983

Cell: (309) 772-0060

Fax (309) 330-7771

Jeff Clark, MD Family Physician

JClark@WillowCreek.com

Office: (309) 454-9827

Cell: (309) 778-4421

Fax: (309) 555-6218

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Resources

1. Abdelhak, Grostick, Haken, Jacobs. Health Information: Management of a

Strategic Resource. 4th Edition. Saunders Company, 2011.

2. OIG.hhs.gov

3. Peden, Ann H. Comparative Health Information Management, 3rd Edition.

Thomson/Delmar Learning, 2012.

4. Tulareregional.org

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Disciplinary Guidelines

To remain reliable, honest, and trustworthy, Willow Creek’s employees must be compliant with

our physician office policies and procedures and federal laws. In an event of misconduct, the

following steps will be enforced based on employee action(s). There are four formal discipline

levels.

Step one:

Level I Reminder is a verbal warning given by the Chief Compliance Officer. The employee’s

misconduct is discussed during a meeting along with corrective action suggestions to prevent a

second occurrence of misconduct.

Step two:

Level II Reminder is a written warning that is recorded in the employee’s file. The Chief

Compliance Officer distributes the discipline form to the employee to sign. Completion of this

form signifies understanding of the misconduct and compliance with disciplinary actions.

Step three:

A Decision-Making Leave is the employee’s final chance to redeem their actions to remain

employed at Willow Creek. The employee is asked to leave work for the day and write an essay

explaining their actions. Their essay should include how they will actively work on steps to

prevent the action from happening again. The essay is reviewed by Chief Compliance Officer. If

the essay shows that the employee is taking their actions seriously and working on attainable

corrections, they will remain employed. If the essay shows lack of understanding and no

corrections, the employee will be terminated.

Policies to Remove Violators

When an employee carries out any of the following actions, the result is immediate termination:

Violates HIPAA

Violates Federal Laws

Displays fraudulent behavior

Performs illegal actions

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Level II Warning Form

To remain reliable, honest, and trustworthy, Willow Creek’s employees must be compliant with

our physician office policies and procedures and federal laws. I, _________________________,

have read/ understand my previous verbal warning and acknowledge the disciplinary actions that

are to follow. If my behavior continues, I recognize that I will be asked to take a Decision-

Making Leave that could result in termination.

Violation:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________________ _________________

Employee Signature Date

_____________________________________ _________________

Compliance Officer Signature Date

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Decision-Making Leave Form

To remain reliable, honest, and trustworthy, Willow Creek’s employees must be compliant with

our physician office policies and procedures and federal laws. I, _________________________,

have read/ understand my previous Level II Warning and acknowledge the disciplinary actions

that are to follow. I recognize that I am being asked to leave work to write an essay explaining

my actions of misconduct and to express corrective solutions for my behavior. I understand that

after writing this essay, termination is a potential outcome.

_____________________________________ _________________

Employee Signature Date

_____________________________________ _________________

Compliance Officer Signature Date

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Termination Form

To remain reliable, honest, and trustworthy, Willow Creek’s employees must be compliant with

our physician office policies and procedures and federal laws. I, _________________________,

understand that I have violated one or all of the following:

Willow Creek Physician Office policies and procedures

Violates HIPAA

Violates Federal Laws

Displays fraudulent behavior

Performs illegal actions

I understand that my signature indicates termination of employment and future employment

opportunities at Willow Creek Physician Office.

_____________________________________ _________________

Employee Signature Date

_____________________________________ _________________

Compliance Officer Signature Date

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Audits

Willow Creek Physician Office should be compliant with federal audit guidelines. A well-

designed compliance program can:

Speed and optimize proper payment of claims

Minimize billing mistakes

Reduce the chances of an audit being conducted by the HCFA or the OIG

Avoid conflicts with self-referral and anti-kickback statutes

Undergoing these periodic audits will help the office to maintain quality output throughout the

facility.

Periodic Audits:

Audits will take place once during each fiscal year after a baseline audit. The audits will occur at

random. The sample of medical records that will be selected for auditing is 8 per physician.

Since this office receives reimbursement from several payors, the auditing/ monitoring process

will consist of reviewing claims from all federal payors.

If a problem is identified in the audit, more extensive and frequent audits will occur. Problems

that were identified during the audit will have more attention focused on them for future training

and education.

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Investigation and Remediation of Systemic

Problems

Investigation:

If an issue arises, root cause analysis will be performed to locate the source of the problem.

Remediation:

1. Collaborate solutions to the problem

2. Choose the best solution

3. Implement the new process

4. Monitor the new process and gather feedback from employees that are involved with the

new implementation