PSOW 2016 - Compliance
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Transcript of PSOW 2016 - Compliance
COMPLIANCE
WHAT DOES COMPLIANCE MEAN?
WHO’S WATCHING?
WHY DO WE NEED IT?
WHAT HAPPENS IF WE DON’T DO IT?
WHAT DO I NEED TO DO?
COMPLIANCE
How many of you have a compliance program? How many of you regularly review PCR for
Medical Necessity? Who is responsible for making sure your
billing company has billable calls? How Many of you know the key elements that
must be identified on each PCR?
COMPLIANCE
What Does Compliance Mean? Meeting certain standards that are set out
by… Individual Department State Agencies Federal Agencies
COMPLIANCE
Federal Agencies & Regulations CMS (Centers of Medicare & Medicaid
Services) OIG (Office of the Inspector General) ACA (Affordable Care Act) FCA (False Claims Act) AKS (Anti-Kickback Statute)
COMPLIANCE
CMS Set Standard for how EMS gets paid Typically contracts with fiscal agent Medicare Benefit Policy – Chapter 10 & 15
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c15.pdf
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf
COMPLIANCE
OIG Office of the Inspector General On March 24, 2003 Federal Register ordered
Creation of Compliance Programs be implemented by Ambulance Providers
Requires 7 steps
COMPLIANCE
1. Compliance Policies & Procedures 2. Designation of a Compliance Officer 3. Develop Education and Training Programs 4. Internal Monitoring and Reviews 5. Responding Appropriately to Detected
Misconduct. 6. Develop Open Lines of Communication 7. Enforcing Disciplinary Standards
COMPLIANCE
Policies & Procedures Training and Education Assessment of Claim Submission Process
Pre-Billing Review of Claims Paid Claims Identification of Risks Response to Identified Risks
COMPLIANCE
Much of this rule is in place to assure that “Outside” influences don’t impact who gets the call…
WHY? $24 Million in first half of 2012 An additional $30 Million paid for transports
where NO Medicare services were provide at either the pick-up or drop off, or anywhere else…
COMPLIANCE
RED FLAGS? Excessive Mileage Up Coding High number of transports per patient SCT Code being used for…
Residence, Skilled Nursing Facility, Free Standing Dialysis Center, etc.
COMPLIANCE
WHO IS WATCHING? Seemingly every Federal Agency
WHY DO WE NEED IT Were you asleep for the last 20 minutes?
WHAT HAPPENS IF WE DON’T DO IT? How much money can you afford to pay in fines
for violations of the various rules WHAT DO WE NEED TO DO?
Be prepared to do a lot of WORK
COMPLIANCE
EXCLUSIONS LIST? What is this? How many of you check it? What if I have an employee on the list?
https://exclusions.oig.hhs.gov/
COMPLIANCE
Internal Audits… How many people are doing internal
billing audits? If you do… How are they done?
COMPLIANCE
How to Determine if call is an EMERGENCY? Dispatch information 9-1-1 call or equivalent Immediate response documented
COMPLIANCE
Medical Necessity Was the transport medically necessary? Did the Documentation paint a picture of need? Was the patient’s problem emergent? Could the patient have gone another way? Is there a difference between “the patient was
assisted to the cot” and “the patient walked to the cot?
COMPLIANCE
Was the patient taken to a covered destination?
Does the PCR explain why certain procedures were done?
Signatures, are they important? Mileage, must be fractional mileage
COMPLIANCE
Over payments What does that mean? What do you have to do if you have been
overpaid?
60 DAY REPAYMENT RULE
COMPLIANCE
BILLING COMPANIES What are they responsible for? Do you get reports from them? Do you ever question the methods they use for
coding? Do they have external auditors validate their
processes?
COMPLIANCE
CODERS ICD 10 CODES MUST BE USED Who does the coding for your service? Are your coders certified? Does the documentation support the code that
was used?