Transcript 2004 FPMP Compliance Plan Training

2004
FPMP Compliance Plan
Training
Brigid M. Maloney, JD
Compliance Officer
[email protected]
(716) 829-3176
2004 Compliance Plan
Reviewed and approved by the FPMP Governing
Board, FPMP Compliance Committee, Clinical
Chairs, and Practice Plan Auditors.
Elements of an
Effective Compliance Plan
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Code of Conduct and written policies and procedures
Compliance monitoring assigned to designated
compliance officer or contact
Comprehensive training and education
Internal monitoring and auditing
Open lines of communication and updates
Disciplinary standards
Investigation and response to detected violations
Program Organization
FPMP Governing Board
 FPMP Compliance Committee
 Vice President for Health Affairs
 FPMP Compliance Officer
 Practice Plan Compliance Coordinators
 Practice Plan Chart Auditors
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Code of Conduct
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Compliance with all laws, regulations, policies and
procedures
Relationship with other providers
Claims with third party payors
Controlled substances
Confidential information
Conflict of Interest
Business information and relationships
Violations
COMPLIANCE PLAN
POLICIES
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1. Education & Training
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Mandatory Annual Training: 2 hours biannually
- educational sessions with your auditor
- classes or seminars offered through FPMP
Compliance Office
- presentations made by outside consultants or
medical billing specialists
- off-site conferences and/or seminars
covering healthcare compliance topics
Education & Training, cont’d
Mandatory New Hire Training:
All new clinical faculty must attend a 1-hour
compliance orientation and training session with
the FPMP Compliance Officer or his/her
designee. New hire training sessions will be
offered twice each year.
2. Documentation
Complete and accurate medical record
documentation is one of the most important
objectives of the Compliance Plan, and a
popular area of investigation by the Office of
the Inspector General and US Attorney.
Documentation, cont’d.
The medical record may be used to validate:
 Site of service
 Appropriateness of services provided
 Accuracy of the billing
 Identity of the health care provider who
furnished the services
Documentation, cont’d.
All medical records must be complete and legible,
and include the following:
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CC and/or reason for encounter
Relevant history
Physical examination & findings by
physician
Prior diagnostic test results
Assessment, clinical impression, or
diagnosis
Plan of Care
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Date and legible identity of the
observer
A statement of the rationale for
ordering diagnostic and other
ancillary services, if not easily
inferred.
Risk factors, patient progress,
response to changes in treatment,
and any revision to diagnosis
Addendums: dated the day the
information is added to the
medical record (not the date the
service was provided).
Documentation, cont’d.
Claims for professional fee reimbursement must:
 Contain proper codes for service provided
 Contain documentation that supports the codes
 Be submitted in the name of the provider who
performed the service.
Documentation, cont’d.
Practice plan responsibilities:
Adopt FPMP Compliance Plan
 Implement own documentation guidelines
 Train and educate clinicians, coders, billers,
administrative staff, and auditors
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Documentation
Some quotes from your peers concerning the E/M Guidelines:
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Stupid (x2)
Compliance is impossible, "medically necessary" is impossible.
Will not improve care, will increase paperwork and will be used to intimidate
physicians
Unnecessary and burdensome
Abusive, intrusive, outrageous, impossible to adhere to
Cumbersome, unnecessary, pain in the neck
Words do lie and liars can write
A process by which the federal government attempts to gain control over medicine
Justifying the jobs of bureaucrats and head hunters.
Part of a systematic breakdown of the physician-patient relationship
Increases my paperwork documentation time by about 25%, and I can charge nothing
[for it]!
A vain attempt to painstakingly ascertain a physician's mental work product
3. Self Referrals & Kickbacks
Anti-kickback Statute
Stark Law
Anti-Kickback Statute
It is unlawful to offer, pay, solicit, or receive any form of
remuneration to induce or in return for:
 Referring or arranging for any item or service payable
under a federal health program; or
 Buying, leasing, or ordering, any good, facility, service
or item payable under a federal health care program.
 Remuneration is defined broadly to include the transfer
of anything of value, in cash or in kind, directly or
indirectly.
Stark Law
Stark II prohibits a physician from making a referral to an
entity for the furnishing of designated health services
(“DHS”) covered by Medicare if the physician (or an
immediate family member of the physician) has a financial
relationship with that entity, unless a statutory exception
exists.
Stark Law
“Designated Health Services”
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clinical laboratory services;
physical therapy services;
occupational therapy services;
radiology services;
radiation therapy services;
durable medical equipment
(DME) and supplies;
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parenteral and enteral nutrients,
equipment, and supplies;
prosthetics, orthotics, and
prosthetic devices and supplies;
home health services;
outpatient prescription drugs;
and
inpatient and outpatient hospital
services.
Stark Law
Referral-A referral may be either a request for any DHS covered by
Medicare, including consultations and the tests or
procedures performed by the consulting physician, or a
plan of care by a physician that includes any designated
health service covered by Medicare.
Financial Relationship—
May be various types of payments, compensation or an
ownership interest.
4. Reporting Misconduct
“All FPMP physicians and their employees are
required to report any incidents of misconduct
of which the physician or employee is directly
aware or suspects.”
 “Failure or refusal to report misconduct or
fraudulent or illegal practices may result in
disciplinary action, including termination.”
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Examples of Misconduct
Improper coding
 Inadequate medical record documentation
 Falsification of medical records
 Acceptance of bribes or other kickbacks
 Unlawful attempt to induce referrals
 Unlawful self-referrals
 Retaliation against someone who has reported a
compliance violation
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5. Internal Audit & Monitoring
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Practice plans are required to review the lesser of 2%
of each physician’s submitted claims, or 20 claims per
year.
Audit results are submitted to the FPMP Compliance
Office.
If physician’s charts are found to be less than 70%
compliant, then internal auditor must conduct an
individual educational session and perform a follow-up
audit.
Compliance rates of 50% or less on three consecutive
audits will automatically trigger an investigation by the
Medical Compliance Officer.
Auditing & Monitoring
Top 10 coding errors
1. No documentation for services billed.
2. No signature or authentication of documentation.
3. Always assigning the same level of service.
4. Billing of consult vs. outpatient office visit.
5. Invalid codes billed due to old resources.
6. Unbundling of procedure codes.
7. Misinterpreted abbreviations.
8. No chief complaint listed for each visit.
9. Billing of service(s) included in global fee as a
separate professional fee.
10. Inappropriate or no modifier used for accurate
payment of claim.
6. Internal Investigations
What triggers an internal investigation?
 Complaint to the Medical Compliance Office
 Irregularities identified through audits
 Threat of civil litigation
 Potential government investigation
 Receipt of a subpoena
Goals of an Internal Investigation
Discover facts & circumstances surrounding
alleged incidents of noncompliance
 Assess legal significance of facts discovered
 Evaluate legal rights and obligations of practice
plan and physician
 Determine if there has been deliberate
wrongdoing
 Stop the wrongdoing
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7. Corrective Action
Mandatory education
 Increased chart audits
 Temporarily suspending billing
 Mandatory prospective audits of all services
before they are billed
 Repayment or voluntary disclosure to
appropriate payors or authorities
 Termination from practice plan
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8. Appeals procedure
Any practice plan member who disagrees with the
corrective action taken or proposed against
him/her by the Medical Compliance Officer
may appeal the corrective action.
9. Governmental Investigations
Traditional areas targeted by government
 Billing for services not rendered
 Billing for services not medically necessary
 Double billing
 Upcoding
 Unlawful kickbacks or referrals
What to do if an Investigator arrives
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Obtain identification
Ask to see documents authorizing the investigation
Request purpose of investigator’s visit
Notify practice plan president or other individuals designated as
contacts
Assure full cooperation with investigators
Remove all non-essential personnel from area
Suspend routine destruction of records
Maintain log of all events associated with investigation
Remember: staff may ask to be interviewed at a later date
10. Updates/Revisions
Minor revisions will be approved by the FPMP
Compliance Committee
 Major revisions must be approved by the
Governing Board
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Other FPMP Compliance Resources
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FPMP Quarterly Newsletter
Compliance Committee meeting minutes
Auditing FAQ’s
Practice Plan Training Guide
Individual Practice Plan Policies & Procedures
A Sound Compliance Program
Reports violations
Newsletter
Training sessions
FPMP
Investigations Compliance
Audit results review
Officer
Written standards FPMP
FPMP
Compliance plan review
Compliance
Compliance
Code of Conduct Plan
Committee
Policy revisions
Practice
Training Guide
Plan
Compliance FPMP
Oversight Governing
Board
Periodic audits
Educational sessions
PP
Corrective action
Compliance
Coordinator
Practice plan oversight
PP Auditor
Reports violations
Auditors meetings
Brigid M. Maloney, J.D.
Compliance Officer
3435 Main Street, BEB Rm. 149
Buffalo, New York 14214
(716) 829-3176
[email protected]