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PSOW 2016 - Compliance

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PSOW 2016 - Compliance

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PSOW 2016 - Compliance

  1. 1. COMPLIANCE ANYONE DOING IT??? Dan Williams
  2. 2. COMPLIANCE  WHAT DOES COMPLIANCE MEAN?  WHO’S WATCHING?  WHY DO WE NEED IT?  WHAT HAPPENS IF WE DON’T DO IT?  WHAT DO I NEED TO DO?
  3. 3. COMPLIANCE How many of you have a compliance program? How many of you regularly review PCR for Medical Necessity? Who is responsible for making sure your billing company has billable calls? How Many of you know the key elements that must be identified on each PCR?
  4. 4. COMPLIANCE What Does Compliance Mean? Meeting certain standards that are set out by… Individual Department State Agencies Federal Agencies
  5. 5. COMPLIANCE Federal Agencies & Regulations CMS (Centers of Medicare & Medicaid Services) OIG (Office of the Inspector General) ACA (Affordable Care Act) FCA (False Claims Act) AKS (Anti-Kickback Statute)
  6. 6. COMPLIANCE CMS Set Standard for how EMS gets paid Typically contracts with fiscal agent Medicare Benefit Policy – Chapter 10 & 15 https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/clm104c15.pdf https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/bp102c10.pdf
  7. 7. COMPLIANCE OIG Office of the Inspector General On March 24, 2003 Federal Register ordered Creation of Compliance Programs be implemented by Ambulance Providers Requires 7 steps
  8. 8. COMPLIANCE 1. Compliance Policies & Procedures 2. Designation of a Compliance Officer 3. Develop Education and Training Programs 4. Internal Monitoring and Reviews 5. Responding Appropriately to Detected Misconduct. 6. Develop Open Lines of Communication 7. Enforcing Disciplinary Standards
  9. 9. COMPLIANCE Policies & Procedures Training and Education  Assessment of Claim Submission Process Pre-Billing Review of Claims Paid Claims Identification of Risks Response to Identified Risks
  10. 10. COMPLIANCE Much of this rule is in place to assure that “Outside” influences don’t impact who gets the call… WHY? $24 Million in first half of 2012 An additional $30 Million paid for transports where NO Medicare services were provide at either the pick-up or drop off, or anywhere else…
  11. 11. COMPLIANCE RED FLAGS? Excessive Mileage Up Coding High number of transports per patient SCT Code being used for… Residence, Skilled Nursing Facility, Free Standing Dialysis Center, etc.
  12. 12. COMPLIANCE WHO IS WATCHING? Seemingly every Federal Agency WHY DO WE NEED IT Were you asleep for the last 20 minutes?  WHAT HAPPENS IF WE DON’T DO IT? How much money can you afford to pay in fines for violations of the various rules WHAT DO WE NEED TO DO? Be prepared to do a lot of WORK
  13. 13. COMPLIANCE EXCLUSIONS LIST? What is this? How many of you check it? What if I have an employee on the list? https://exclusions.oig.hhs.gov/
  14. 14. COMPLIANCE Internal Audits… How many people are doing internal billing audits? If you do… How are they done?
  15. 15. COMPLIANCE
  16. 16. COMPLIANCE DOCUMENTATION PCR’S WHAT DO YOURS LOOK LIKE
  17. 17. COMPLIANCE How to Determine if call is an EMERGENCY? Dispatch information 9-1-1 call or equivalent Immediate response documented
  18. 18. COMPLIANCE Medical Necessity Was the transport medically necessary? Did the Documentation paint a picture of need? Was the patient’s problem emergent? Could the patient have gone another way? Is there a difference between “the patient was assisted to the cot” and “the patient walked to the cot?
  19. 19. COMPLIANCE Was the patient taken to a covered destination? Does the PCR explain why certain procedures were done? Signatures, are they important? Mileage, must be fractional mileage
  20. 20. COMPLIANCE Over payments What does that mean? What do you have to do if you have been overpaid? 60 DAY REPAYMENT RULE
  21. 21. COMPLIANCE BILLING COMPANIES What are they responsible for? Do you get reports from them? Do you ever question the methods they use for coding? Do they have external auditors validate their processes?
  22. 22. COMPLIANCE CODERS ICD 10 CODES MUST BE USED Who does the coding for your service? Are your coders certified? Does the documentation support the code that was used?
  23. 23. NOW THAT WE ARE DONE BLOWING OFF SOME STEAM…
  24. 24. WE HAVE HIT THE FINISH LINE
  25. 25. QUESTIONS??

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