Skills Competency Education for New PI Directors and Coordinators. Session Six March 28, 2006 Sponsored by: The MT Rural Healthcare PI Network Co-Sponsored by: The Mountain Pacific Quality Health Foundation. Session Six Learning Goals.
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Session Six March 28, 2006
Sponsored by: The MT Rural Healthcare PI Network
Co-Sponsored by: The Mountain Pacific Quality Health Foundation
To understand the critical role that policies and procedures perform in organization communication;
To understand the role of policies and procedures in managing organization medical-legal risk;
To understand the difference between a policy and a procedure;
To share guidelines for policy and procedure development.
·Risk Identification.The first element of a Compliance Plan is the development and distribution of written policies and procedures that identify specific areas of risk to the hospital.
·Standards of Conduct. Hospitals should develop standards of conduct that:
·Risk Areas. The OIG Guidance focuses on specific areas of potential fraud and provides specific examples of policies that should be implemented to ensure compliance in these areas.
·Claims Development and Submission Processes and Code Gaming (upcoding, DRG creep). There should be policies that create a mechanism for the billing or reimbursement staff to communicate effectively and accurately with the clinical staff.
·Ensuring That Claims Are Submitted Only for services that are medically necessary and that were ordered by a physician or other appropriately licensed individual.
·Anti-Kickback and Self-Referral Concerns. The hospital should have policies and procedures in place with respect to compliance with Federal and State anti-kickback statutes, as well as the Stark physician self-referral law.
·Accurate and Timely Reporting of Bad Debts andCredit Balances to Medicare and other Federal health care programs.
·Records System. There should be a records system which should establish policies and procedures regarding the creation, distribution, retention, storage, retrieval and destruction of documents.
Administrative • Departmental Level
Credentialing ■ Laboratory
Human Resources ■ Radiology
Purchasing ■ Medical Records
DisasterEXAMPLES OF POLICY MANUALS