Transcript 2004 FPMP Compliance Plan Training

2004
FPMP Compliance Plan
Training
Brigid M. Maloney, JD
Medical Compliance Officer
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
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FPMP Governing Board
FPMP Compliance Committee
Vice President for Health Affairs
Medical Compliance Officer
Practice Plan Compliance Coordinators
Practice Plan Chart Auditors
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
Workplace environment issues
Business information and relationships
Violations
COMPLIANCE PLAN
POLICIES
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1. Education & Training
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New hire orientation
Existing employees: 2 hours per year
Electronic Newsletter
Auditor’s educational sessions
Seminars
Sessions arranged through Medical Compliance
Office
2. Documentation
Complete and accurate medical record
documentation is one of the most important
objectives of the Compliance Plan, and a
favorite area of investigation by the Office of
the Inspector General.
Documentation
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 servicese
Documentation
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All medical records must be complete and legible, and include
the following:
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
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
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.
Documenation
Practice plan responsibilities:
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Adopt FPMP Compliance Plan
Implement own documentation guidelines
Train and educate clinicians, coders, billers,
administrative staff, and auditors
Documentation
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PATH Requirements
Documentation
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Non-physician practitioners
3. Self Referrals & Kickbacks
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Stark Law
Anti-kickback Law
4. Reporting Misconduct
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“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.”
Examples of Misconduct
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Improper coding
Inadequate medical record documentation
Falsification of medical records
Harassment
Acceptance of bribes or other kickbacks
Unlawful attempt to induce referrals
Retaliation against someone who has reported a
compliance violation
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 Medical 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.
6. Internal Investigations
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What triggers and 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
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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
7. Corrective Action
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Medical Compliance Officer may recommend
Corrective Action be taken by the practice plan
president or Vice President for Health Affairs.
Mandatory education
Increased chart audits
Temporarily suspending billing
Repayment or voluntary disclosure to appropriate
payors
Reporting violation to appropriate authorities
Termination from practice plan
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
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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
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Minor revisions will be approved by the FPMP
Compliance Committee
Major revisions must be approved by the
Governing Board
Other FPMP Compliance Resources
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FPMP Quarterly Newsletter
Compliance Committee meeting minutes
Auditors meeting minutes
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
Policy revisions
Code of Conduct Plan
Committee
Practice
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.
Medical Compliance Officer
3435 Main Street, BEB Rm. 149
Buffalo, New York 14216
(716) 829-3176
[email protected]