Transcript Operationalizing “Compliance”

Operationalizing “Compliance”
Anthony Guerrero, M.D.
Associate Professor of Psychiatry and Pediatrics
Vice-Chair for Education and Training, Psychiatry
Objectives



To give a practical overview of things commonly
associated with regulatory “compliance”: billing
and coding compliance, STARK, EMTALA,
perhaps other fancy acronyms.
To outline basic resources and generic steps in
creating a voluntary compliance program.
Assumption: basic orientation to compliance
relevant to residency training; this presentation
will focus on what you may need to expect after
residency.
Personal message
We want you to be successful in whatever
practice you choose.
 We want to help you stay out of unintended
trouble.
 We want you to feel comfortable taking care
of public-sector patients and patients on
governmentally sponsored insurance plans.

Say what? Let’s play “matching”:
1.
Billing and coding
compliance
A.
B.
2.
HIPAA
C.
3.
STARK
D.
4.
EMTALA
5.
CFR 42
E.
Relates to assessment and
stabilization of patients
Relates to privacy
Relates to substance
abuse treatment
Relates to accurate
documentation and
preventing
erroneous/fraudulent
claims
Relates to anti-kickback
rules
Answers: 1. D. 2. B. 3. E. 4. A. 5. C.
Case Scenarios

In preparation for private practice, which
you plan to start right after graduation, you
run through a checklist of all the things you
need to take care of. Did you make sure to
include things like “compliance” and
“HIPAA?”
Case Scenarios

You are interviewed for an appealing job at
an agency that recently came under a
“corporate integrity agreement.” You
wonder what this means, and what the
implications are for your practice with
them.
Why should I bother?

Can anyone tell me?
Remember that quality is the
driver of patient care processes
Nearly every other industry – e.g., airline
industry, etc. – has rules to follow.
 Error reduction is a key principle: reduces
waste, improves quality

Individual/small group practices





Let’s start off with the DHHS/OIG guidelines for
compliance programs…
http://oig.hhs.gov/authorities/docs/physician.pdf
Probably one of the most important websites
you’ll ever encounter!
Wonderful examples of fraud, and everything
you’d ever want to know about penalties!
A voluntary compliance program is MUCH better
than an involuntary one
Main principles
Claims submitted to federal health care
programs
 Private payor claims may also be covered
by a compliance plan

Main principles







Internal monitoring and auditing
Written standards and procedures
Compliance officer or contacts
Training and education
Responding appropriately to possible violations
Open lines of communication for education and
monitoring
Well-publicized disciplinary standards
Component 1: Internal
monitoring and auditing
Accurate billing and coding
 Accurate documentation
 Consider templates
 Know your references
 Reasonable-ness and necessity of services
 Absence of incentives for unnecessary
services

Component 1: Internal
monitoring and auditing




The OIG recommends that claims/services that
were submitted and paid during the initial three
months after the education and training program
be examined
Periodic audits should be conducted at least once
per year
5+ medical records per federal payor; 5-10 per
physician
Action plan (e.g., repayment, correction of
processes, training, etc.) for problems uncovered
Quick quiz: can anyone define
for me…
90801
 90805
 90807
 90846
 90847
 90862

Quick quiz:
How exactly do insurance companies know
what services you provided and for what?
 What pieces of information do they need to
know, and how do they get that
information?

Component 2: Standards and
Procedures




Keep these in a binder!
Having policies and procedures will save you!
Can cross-reference AMA ethics guidelines
“Risk areas” to cover:
 Coding and billing
 Reasonable and necessary services
 Documentation (including reasons for services,
location of services)
 Improper inducements, kickbacks, and selfreferrals
Practical examples



If I saw a patient for 2 hours of psychotherapy (I
couldn’t help it, they kept talking), can I bill them
for 2 visits on 2 separate days, since I did the
work?
If I spent 30 minutes talking to a patient over the
phone (once again, I couldn’t help it), and then
calling in a prescription to the pharmacy, can I bill
for a medication management or psychotherapy
visit?
Can I waive someone’s co-pay? They’re having a
difficult time right now and under a lot of
emotional distress.
Practical examples
I’m interested in a primary care liaison
model. A group of internists wants to lease
me office space at a good rate. Is there
anything I need to be careful of?
 I’m a combined primary care/psychiatry
graduate. Can I have a combined primary
care/psychiatry practice and refer patients to
myself?

Practical examples



I’m planning to work in a public-sector clinic
where senior residents rotate. I was told that I
only need to sign their notes. Is that true?
I’m on-call for the psychiatry ED service. What
does this mean in terms of whom I am obligated to
treat?
I’m interested in making a lot of money. What do
I need to be careful of if I start a “walk in”
psychiatry clinic?
Component 3: Compliance
Officer
Overseeing implementation and insuring the
up-to-dated-ness of the compliance program
 Coordinating periodic audits
 Coordinating training
 Checking OIG’s black-list
 Investigating problems and insuring
corrective action

Component 4: Training and
Education
Compliance in general: rules and penalties
 Coding and billing
 CPT
 ICD-9
 Should have at least annual training
 Document any training activity; remember
your binder!

Component 5: Responding to
possible violations
Overpayment issues
 Individual correction
 Systems correction
 Possibility of criminal violations
 Know your resources

Component 6: Open lines of
communication
People shouldn’t be intimidated from doing
what’s necessary to insure regulatory
compliance
 Exchange of information

Component 7: Disciplinary
standards
Should be a part of initial and ongoing
orientation
 Main theme is accountability

Generic steps that could benefit
any patient care process


Key ingredients:
 Sound philosophy (quality, efficiency)
 Policies and procedures
 Forms to insure that things are done uniformly
and painlessly
 Quality improvement principles (plan, do,
check, act; monitoring and correction;
mechanism to continuously update)
 Administrative structure; people
 Education and training and accountability
Ever wonder how the airline industry does it?
Similar processes with HIPAA
compliance





Policies and procedures, based on HIPAA laws,
for anything involved in transaction of information
Forms (privacy practices, consent forms) to insure
that things are done uniformly and painlessly
Quality improvement principles (plan, do, check,
act; monitoring and correction; mechanism to
continuously update)
Administrative structure; people (privacy officer)
Education and training and accountability
Relevant to psychiatry
Can refer to frequently asked questions
about HIPAA:
http://www.hhs.gov/ocr/hipaa/
 CFR 42 is very important!


PART 2--CONFIDENTIALITY OF
ALCOHOL AND DRUG ABUSE PATIENT
RECORDS:
http://www.access.gpo.gov/nara/cfr/waisidx_03/42cfr2_03.html
Technology: the wave of the
future
Computerized, customizable packages for
HIPAA compliance
 Useful websites are posted on our very own
DOP website:
http://dop.hawaii.edu

Thank you for your attention!
Good luck!
Anthony Guerrero, M.D.
[email protected]