This Session is CEU Approved

2. This Session is CEU Approved http://www.surveymonkey.com/s/NAAC_Certs

3. Compliance…That’s Your Job!Presented by:Renee Collier Implementation SpecialistZOLL

4. 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

5. OIG Most Wanted

6. Compliance in Ambulance Billing Who’s responsible? • Management

7. Compliance in Ambulance Billing Who’s responsible? • Field Crews

8. Compliance in Ambulance Billing Who’s responsible? • Coders/Billers

9. Objectives • Review OIG’s Ambulance Service Compliance Program Guidelines • Review Self Audit Protocol

10. The Plan • Federal Register/Vol.68, No.56 • OIG Voluntary Program Guidance - Mandatory in 2014 • Guidelines – Not A One Size Fits All • Highly Recommended

11. Document Overview • Produced June 2002 • Outlines most common issues of fraud and abuse. • Basically looks to: Identify Prevent Correct

12. 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

13. 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.

14. 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.

15. 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

16. 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.

17. 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.

18. 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.

19. 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?

20. 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.

21. 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.

22. Claims Submission • Use baseline audit to develop benchmarks. • Use external benchmarks as well. • Document audit dates and outcomes. • Use outcomes to drive training.

23. 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!

24. Paid Claims Review • Under/Overpayments • An overpayment is one that has been received in excess amounts due and payable under Medicare statute and regulations.

25. Paid Claims Review • What causes overpayments? • Duplicate submission of same service or claim • Payment to the incorrect payee • Payment 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.

26. 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.

27. Denials in RescueNet

28. 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.

29. 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

30. 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

31. Response to Risks • Develop written response protocols. • Address issues in a timely manner. • Document, document, document!

32. 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.

33. Upcoding • Charging ALS service charge for a BLS call. • Charging for services not rendered.

34. 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

35. 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

36. Scheduled/Unscheduled Transports • Obtain PCS • Routine Doctor/Dialysis • More appropriate transport available • Do NOT submit inappropriate claims to Medicare.

37. Documentation, Billing & Reporting • Inadequate/Faulty Documentation = High Risk • Dispatch • Transport Personnel • Coders/Billers

38. 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

39. 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?

40. Part A Part A Agreements 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. • Contractual Agreements • Not billable to Medicare • High risk to violate Anti-Kickback Statute

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

42. Additional Risks • No transport • Multiple Patient • Multiple Agency Response • Billing In Excess

43. 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

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

45. 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

47. 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

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