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Compliance. Todd Phillips Thousand Cranes. INTERNAL MONITORING AND AUDITING. GOAL

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compliance

Compliance

Todd Phillips

Thousand Cranes

internal monitoring and auditing
INTERNAL MONITORING AND AUDITING
  • GOAL
  • In order to ensure the efficacy of Thousand Cranes Compliance efforts, and in order to determine whether Thousand Cranes is in compliance with applicable laws and regulations, we will engage in an ongoing effort to monitor and audit our billing and coding practices.
  • POLICY AND PROCEDURE
  • Thousand Cranes will monitor and audit its compliance efforts as follows:
  • Baseline audit: Within sixty (60) days of adopting this compliance manual, Thousand Cranes will randomly select 25 previously submitted Medicare claims for review by an independent coding expert.
  • Ongoing audits: Every six (6) months following the baseline audit, Thousand Cranes will randomly select 10 previously submitted Medicare claims for review by an independent coding expert.
  • Thousand Cranes will review all denied claims by Medicare in order to determine the reason for the denial.
  • In reviewing the results from the above-referenced procedures, Thousand Cranes will make those changes necessary to ensure that proper coding and billing practices are adhered to and, if necessary, that changes are made in current billing and coding practices.
screening of employees and contractors
SCREENING OF EMPLOYEES AND CONTRACTORS

GOAL

  • To hire and retain honest and ethical employees, in particular employees who have not been sanctioned by or excluded from any government health care program. In addition, to hire outside contractors and vendors who maintain high professional standards and who have not been barred from state or federal programs.
  • POLICY AND PROCEDURE
  • Thousand Cranes will screen prospective employees by:
    • Using the Employee Applicant Questionnaire (Appendix A);
    • Asking appropriate questions in job interviews; and/or
    • Checking the OIG website for the list of excluded individuals (http://oig.hhs.gov/fraud/exclusions.html.)
  • Thousand Cranes will screen prospective contractors and vendors by:
    • Checking the OIG website for excluded individuals (http://oig.hhs.gov/fraud/exclusions.html); and
    • Checking the OIG website for barred contractors (http://epls.arnet.gov).
employee training and education
EMPLOYEE TRAINING AND EDUCATION
  • GOAL
  • Thousand Cranes will ensure that its employees have sufficient training and education to understand and follow basic compliance principles and to competently and properly perform their duties.
  • POLICY AND PROCEDURE
  • Thousand Cranes will educate and train its employees by:
  • Providing all employees with a copy of this Medicare Compliance Manual;
  • Maintaining a compliance library with current coding reference materials and Medicare carrier bulletins accessible to all employees;
  • Sending Thousand Cranes employees to appropriate seminars and programs regarding Medicare compliance and billing and coding issues.
  • Training and education through self-study of materials in Thousand Cranes compliance library, as well as communications received from the Medicare carrier, will be the primary means of employee education and training in Thousand Cranes. Employee training and education will be recorded by the Compliance Officer in the Training and Education Record
non retaliation policy
NON-RETALIATION POLICY
  • GOAL
  • To encourage all employees, without fear of retribution or retaliation, to report instances of conduct that violate the policies and procedures in this Manual.
  • POLICY AND PROCEDURE
  • This Medicare Compliance Manual will be provided to all Thousand Cranes employees, along with this statement of policy that Thousand Cranes employees are to report any instances of perceived improper or inappropriate conduct with respect to coding and billing or other compliance matters contained herein.
  • Compliance violations should be reported to the Compliance Officer.
  • Thousand Cranes will not take any adverse employment action against employees who report potential Medicare compliance violations.
response to compliance violations and preventative measures
RESPONSE TO COMPLIANCE VIOLATIONSAND PREVENTATIVE MEASURES
  • GOAL
  • To ensure the integrity of the compliance plan, Thousand Cranes will respond to violations of the policies and procedures in this Manual. Further, Thousand Cranes will take the necessary steps to prevent similar violations from occurring in the future.
  • POLICY AND PROCEDURE
  • All reports of potential violations of the compliance plan will be investigated by the Compliance Officer. The Compliance Officer will record the results of the investigation on the Incident Report Form (Appendix C) and maintain this documentation.
  • Based upon the investigation by the Compliance Officer, appropriate steps will be taken to ensure that the violation is not repeated. Such steps may include employee training, education and/or discipline. If necessary, this Manual will be amended to prevent further violations.
  • To the extent that overpayments are discovered as a result of the Compliance Officers investigation, a refund will be promptly made to Medicare.
coding and billing
CODING AND BILLING
  • GOAL
  • To ensure that Thousand Cranes follows appropriate coding and billing practices in compliance with Medicare rules, regulations and laws.
  • POLICY AND PROCEDURE
  • Thousand Cranes will keep and maintain updated coding and reference materials, including CPT, ICD-9 and HCPCS manuals.
  • Thousand Cranes will retain and review all bulletins and information received from the Medicare carrier.
  • Billing and coding personnel will follow appropriate coding rules as set forth in the compliance reference materials maintained by Thousand Cranes.
  • Thousand Cranes will bill Medicare only for covered services; however, if requested by the patient, or if necessary to obtain payment from a secondary payer, Thousand Cranes will submit the claim to Medicare with appropriate modifiers reflecting that the service is not covered and that the claim is submitted solely for the purpose of obtaining a denial.
  • Thousand Cranes will bill Medicare only for services that have been documented in the records of Thousand Cranes.
  • Thousand Cranes will bill Medicare only for medically necessary services; however, if requested by the patient, or if necessary to obtain payment from a secondary payer, Thousand Cranes will submit the claim to Medicare with appropriate modifiers reflecting that the patient has signed an Advance Beneficiary Notice and that the claim is submitted for purposes of obtaining a determination by Medicare. ( Advance Beneficiary Notices)
enforcement of compliance policies and procedures
ENFORCEMENT OF COMPLIANCEPOLICIES AND PROCEDURES
  • GOAL
  • To ensure the strict enforcement of all provisions of this Manual. Further, to initiate appropriate disciplinary action for violation of the policies set forth in this Manual, as well as any violation of Medicare laws, rules or regulations.
  • POLICY AND PROCEDURE
  • The Compliance Officer will provide this Manual to all Practice personnel and will advise them that adherence to its provisions is a condition of employment.
  • Practice personnel who violate the policies and procedures in this Manual will be subject to discipline, which may include termination of employment, as determined by the Compliance Officer after appropriate investigation
co payments and deductibles
CO-PAYMENTS AND DEDUCTIBLES
  • GOAL
  • To ensure that Thousand Cranes complies with Medicare rules and regulations regarding co-payments and deductibles.
  • POLICY AND PROCEDURE
  • Thousand Cranes will not routinely waive co-payments and deductibles of Medicare patients.
  • Thousand Cranes will allow a waiver of co-payments or deductibles only where there is documentation of financial hardship from the patient.
  • Absent documentation of financial hardship, Thousand Cranes will undertake reasonable collection efforts by sending reminder billings to patients and/or referring the matter to collection.
  • Waivers of co-payments or deductibles will not in any circumstances be given to potential referral sources.
  • Thousand Cranes will not advertise waiver of co-payments or deductibles or an insurance billing only.
credit balances
CREDIT BALANCES
  • GOAL
  • To establish proper procedures for handling credit balances on patient accounts.
  • POLICY AND PROCEDURE
  • Thousand Cranes shall issue refund request on credit balances to Medicare, the patient or third-party payers within a reasonable time. Absent justifiable circumstances, such refunds generally will be made by the end of the month or within thirty (30) days.
advance beneficiary notices
ADVANCE BENEFICIARY NOTICES
  • GOAL
  • To ensure proper use of Advance Beneficiary Notices to properly notify patients and prevent liability to Thousand Cranes.
  • POLICY AND PROCEDURE
  • Thousand Cranes will request a Advance Beneficiary Notice (ABN) form in situations where Medicare may deny payment due to lack of medical necessity, but where the services would otherwise be covered by Medicare.
  • The ABN forms must be signed by the patient prior to services being rendered.
  • Thousand Cranes will use the CMS authorized ABN form, attached hereto as Appendix D to this manual.
  • The ABN form will be filled out to specifically describe the service or procedure and the reason for Medicare’s potential denial of payment.
  • Improper or indiscriminate use of ABN forms will be avoided by Thousand Cranes.
business relationships
BUSINESS RELATIONSHIPS
  • GOAL
  • To ensure that Thousand Cranes’s business relationships and contracts do not violate state and federal laws.
  • POLICY AND PROCEDURE
  • Thousand Cranes will endeavor to ensure that all of its business relationships and contracts comply with state and federal laws by:
  • Having all contracts with other health care providers, vendors, or others, reviewed by health care counsel.
  • Requiring that all contracts entered into by Thousand Cranes will be at fair market value and in writing.
  • Prohibiting Thousand Cranes employees from receiving or giving “inducements” to referral sources.
professional courtesy
PROFESSIONAL COURTESY
  • GOAL
  • To ensure that professional courtesy arrangements do not violate fraud and abuse laws.
  • POLICY AND PROCEDURE
  • A Professional courtesy means providing services without charge (in whole or in part) to Practice employees, other physicians, and/or their families in relation to services provided by Thousand Cranes. Thousand Cranes may extend professional courtesy, as so defined, only if the following conditions are met:
  • The professional courtesy is provided in a manner that does not take into account the recipient’s ability to generate referrals for Thousand Cranes;
  • The total value of the services for which professional courtesy is extended may not exceed $300.00 per person annually;
  • Thousand Cranes may not waive co-payments or deductibles only.
financial records
FINANCIAL RECORDS
  • GOAL
  • To maintain and preserve accurate financial records.
  • POLICY AND PROCEDURE
  • Accurate business records will be maintained by Thousand Cranes at all times. All payments or receipts will be recorded in detail in Thousand Cranes business records. With the exception of disbursements from petty cash funds, Thousand Cranes will not make cash payments.
records management and retention
RECORDS MANAGEMENT AND RETENTION
  • GOAL
  • To ensure proper maintenance and retention of the records of Thousand Cranes.
  • POLICY AND PROCEDURE
  • Thousand Cranes will create, maintain and retain those documents required by law and necessary to its operations. In particular, all records and documentation substantiating or supporting Medicare billing submissions will be retained by Thousand Cranes.
  • The documents and records created by this Practice will be retained for the time required by law and in the manner required by law. Currently, it is Thousand Cranes policy to retain medical records 7 years.
  • If and when it is determined that records will be destroyed, this will occur by shredding or in another manner necessary to obliterate confidential information, including patient name, Social Security number, Medicare number and any other potentially identifying information
privacy and confidentiality
PRIVACY AND CONFIDENTIALITY
  • GOAL
  • To ensure compliance with state and federal privacy and confidentiality laws with respect to health information.
  • POLICY AND PROCEDURE
  • Thousand Cranes will follow all state and federal laws relating to patient privacy and confidentiality.
  • Thousand Cranes will implement appropriate safeguards to prevent improper use or disclosure of patient health information.
  • Thousand Cranes will not release or disclose patient health information without a signed authorization from the patient.