COMPLIANCEANYONE DOING IT???Dan Williams

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

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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

COMPLIANCE

DOCUMENTATIONPCR’SWHAT DO YOURS

LOOK LIKE

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?

NOW THAT WE ARE DONE BLOWING OFF SOME STEAM…

WE HAVE HIT THE FINISH LINE

QUESTIONS??