The document prepared for the THIMA 2018 annual meeting discusses the importance of compliance in healthcare and the role of Health Information Management (HIM) in supporting an effective compliance program. It outlines the seven essential elements of a robust compliance program, emphasizes the benefits of compliance in preventing fraud and improving patient care, and highlights regulatory requirements such as the Patient Protection and Affordable Care Act. The presentation also addresses specific compliance challenges and reimbursement guidelines related to non-physician providers in the Medicare system.

1. Kristen Lilly, MHA, CHC®, CPHQ, RHIA®
PYA
2018 ANNUAL MEETING
TENNESSEE HEALTH INFORMATION MANAGEMENT ASSOCIATION
How HIM Supports the Seven Elements
of an Effective Compliance Program

2. Prepared for THIMA 2018 Annual Meeting Page 1
Agenda
 What is compliance and why is it important?
 Understand the seven elements of a robust compliance
program as outlined in the Federal Sentencing
Guidelines
 Review the regulatory guidance surrounding compliance
programs
 Identify HIM’s role in organization compliance
 Discuss the intersection between HIM and compliance

3. What Is Compliance and Why Is It
Important?

4. Prepared for THIMA 2018 Annual Meeting Page 3
What Is Compliance?

5. Prepared for THIMA 2018 Annual Meeting Page 4
Definition of Compliance
General Definition of Compliance
 Meeting the expectations of others
Compliance for Healthcare Providers
 Activities that assist organizations and providers with
conducting operations and activities ethically, with the
highest level of integrity, and in compliance with legal
and regulatory requirements
 Help prevent violations and reduce risk and liability to
the provider organization

6. Prepared for THIMA 2018 Annual Meeting Page 5
Compliance Guideline
3) https://www.justice.gov/criminal-fraud/page/file/937501/download
4) https://oig.hhs.gov/compliance/101/files/HCCA-OIG-Resource-Guide.pdf
1) https://oig.hhs.gov/
2) https://www.ussc.gov/sites/default/files/pdf/guidelines-manual/2016

7. Prepared for THIMA 2018 Annual Meeting Page 6
CMS Mandates for Compliance
 Section 6401 of the Patient Protection and Affordable
Care Act (PPACA), enacted March 23, 2010, mandates
that all healthcare providers enrolled in Medicare,
Medicaid, and the Children’s Health Insurance Program
(CHIP) establish a compliance program as a condition of
enrollment1
 CMS believes that compliance efforts are fundamentally
designed to establish a culture within an organization
that promotes the prevention, detection, and resolution
of instances of conduct that do not conform to federal
and state law, or to federal healthcare program
requirements2
1) 42 U.S.C. § 1395cc(j)(8). Section 6401,Health and Human Services (HHS)
2) Compliance Program Guidance for Medicare Fee-For-Service Contractor, March 2005, Health and Human Services (HHS)

8. Prepared for THIMA 2018 Annual Meeting Page 7
Compliance Program Essentials
 A Compliance Program establishes and maintains a
“culture of compliance”
 A Compliance Program is a series of internal controls,
monitoring activities, and metrics to help organizations
meet the requirements of state and federal regulatory
agencies
 A Compliance Program provides an opportunity for
organizations to identify and correct potential risk areas
that may otherwise be obscured

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Benefits of a Solid Compliance Program
 Compliance is vital in deterring fraud and abuse
 The ultimate goal is to create an ethical, comfortable
corporate culture
 Patient care is improved when healthcare decisions are
based on proper motives
 When fraud and abuse happen, an effective Compliance
Program will mitigate the risk of undetected non-
compliance

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Who Is Subject to Compliance?
EVERYONE IN THE ORGANIZATION
Officers
Board
Members
Employees
Physicians
NPPs
Students
Vendors
Contractors
Volunteers

11. The Seven Elements of an Effective
Compliance Program and HIM’s Impact

12. Prepared for THIMA 2018 Annual Meeting Page 11
Seven Elements of an Effective Compliance
Program
The seven elements identified in the 1991 Federal Sentencing Guidelines for
Organizations (Guidelines) are the primary indicators of the federal
government’s expectations for effective compliance activities
High-Level
Oversight
Policy and
Procedure
Integration
Open
Communication
Training and
Education
Monitoring and
Auditing
Response to
Detected Errors
Consistent
Enforcement

13. High-Level Oversight

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Tone at the Top
 “Tone at the top”
 The tone at the top is the foundation of an effective compliance
program and begins with the Board’s oversight responsibility,
followed by the CEO’s commendation of the program, support by
a senior leadership team, and a CCO that facilitates
organization-wide accountability for compliance issues
 Board oversight
 CEO’s commendation of the compliance program
 The Individual Accountability for Corporate Wrongdoing
(Yates Memo)
https://oig.hhs.gov/newsroom/news-releases/2015/guidance-release2015.asp
https://www.justice.gov/dag/file/769036/download

15. Prepared for THIMA 2018 Annual Meeting Page 14
Program Oversight
 Compliance Officers and Committees oversee the compliance
program, including:
 Reviewing Code of Conduct and making recommendation to the
Board for approval
 Understanding and administering the compliance program
structure
 Being informed of audits and monitoring outcomes
 Reporting on compliance enforcement activity
 Reviewing and performing assessments on the effectiveness of
the compliance program
 HIM Impact:
 Reporting of auditing and monitoring results to the
compliance committee

16. Policies and Procedures

17. Prepared for THIMA 2018 Annual Meeting Page 16
Compliance Policies and Procedures
 Policies and procedures are used to document how the
organization will comply with federal and state laws as well as
contractual or accreditation standards when conducting its
operations
 Well-documented and updated policies and procedures allow
for detection of possible compliance issues; for example,
missed steps in procedures or not following the procedure in
the right order can signal possible issues
 HIM Impact:
 Coding productivity and quality policies
 Physician delinquency policy
 Medical record policies

18. Open Lines of Communication

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Open Lines of Communication
 For a Compliance Program to be effective, the workforce
must be able to ask questions and report problems; in some
cases, workforce members might have an obligation to report
a concern
 The Compliance Office must be a resource for clarification
of policies, procedures, and regulations; and the Compliance
Office must partner with business leadership to communicate
about identified issues and how they are resolved
 Effective programs also allow for anonymous reporting of
issues and concerns (e.g., compliance hotline number and/or
website)
 HIM Impact:
 Obligation to report wrong-doing (e.g., coding/billing concerns)

20. Training and Education

21. Prepared for THIMA 2018 Annual Meeting Page 20
Training and Education
 General compliance training that effectively communicates
requirements of Compliance Program to all employees
 Initial training for new employees occurring at, or near, the date
of hire
 Annual refresher training for existing employees
 HIM Impact:
 Specific/customized training for specialty areas such as coding
and billing

22. Consistent Enforcement

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Consistent Enforcement
 Written policies are required that apply appropriate
disciplinary sanctions on those who fail to comply with
applicable requirements and written standards of conduct
These disciplinary policies should include sanctions for:
 Non-compliance
 Failure to detect non-compliance when routine observation or
due diligence should have provided adequate information
 Failure to report actual or suspected non-compliance
 Discipline must be dealt with timely and enforced consistently
 HIM Impact:
 Coding productivity and quality thresholds

24. Response to Detected Errors

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Investigations and Corrective Action
 Issues that are identified must be reported quickly and then
thoroughly investigated and corrected
 When vulnerabilities or non-conformances are identified,
corrective action must be conducted in response to the
potential violations
 Corrective action can include activities like updating policies
and procedures, retraining employees, correcting claims
submitted or refunding overpayments and making information
technology changes; corrective action might also include
employee discipline, where appropriate
 HIM Impact:
 Disciplinary action plan development and monitoring in
response to detected issues (i.e., failing to meet coding quality
thresholds)

26. Auditing and Monitoring
HIM’s Biggest Impact

27. Prepared for THIMA 2018 Annual Meeting Page 26
Auditing and Monitoring Overview
 A system for auditing and monitoring must be implemented to:
 Measure the effectiveness of the Compliance Program
 Ensure compliance with legal, regulatory, internal policy and
contractual requirements
 Identify compliance risks
 Difference between Auditing and Monitoring:
 Monitoring is performing regular reviews as part of normal
operations to confirm ongoing compliance
 Auditing is formal reviews of compliance with a particular set of
standards as base measures
 Includes periodic risk assessment and work plans to focus
auditing and monitoring activities

28. Prepared for THIMA 2018 Annual Meeting Page 27
Areas Where Compliance Risk May Exist
 Patient information
 Relationships with physicians
 Licensure and certification renewals
 Billing practices
 AUDITING & MONITORING - HIM’s BIGGEST IMPACT TO
ORGANIZATIONAL COMPLIANCE!

29. Auditing and Monitoring Spotlight
Documentation Accuracy

30. Prepared for THIMA 2018 Annual Meeting Page 29
Quality of Provider Documentation Impacts
Key Areas of Performance
SEVERITY
OF
ILLNESS
REIMBURSEMENT
CASE
MANAGEMENT
RISK
MANAGEMENT
QUALITY
MANAGEMENT
VALIDATION
OF
LOS
UTILIZATION
OF
RESOURCES
AUDITS
(RAC, MAC,
MCOs)
CASE
MIX
INDEX
PHYSICIAN
PROFILING
RISK
OF
MORTALITY
ACCURATE
CLINICAL
CODING
PROVIDER
DOCUMENTATION

31. Prepared for THIMA 2018 Annual Meeting Page 30
Quality Documentation
 Documentation for coding
 Documentation billing (e.g., modifiers)
 Documentation for quality reporting (POAs, HACs, etc.)
 The role of Clinical Documentation Improvement
Specialist
 The ultimate role of the coder to ensure compliance

32. Prepared for THIMA 2018 Annual Meeting Page 31
Effect of Billing and Coding Integrity
 The quality of healthcare across the continuum
depends on the integrity, reliability, and accuracy
of health information
 Documentation
 Coding
 Billing
 Lack of integrity results in Fraud, Waste, and
Abuse (FWA)
 FWA triggers legal and regulatory intervention,
including fines, penalties, sanctions, exclusion,
and incarceration

33. Prepared for THIMA 2018 Annual Meeting Page 32
Definitions of FWA: Fraud
Fraud:
 The intentional deception or misrepresentation that an
individual knows, or should know to be false, or does not
believe to be true, and makes, knowing the deception
could result in some unauthorized benefit to himself or
some other person(s)
 To purposely bill for services that were never given, or to
bill for a service that has a higher reimbursement than
the services produced
Source: CMS https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/fwa-presentation-handout.pdf

34. Prepared for THIMA 2018 Annual Meeting Page 33
Definitions of FWA: Waste
Waste:
 Incurring unnecessary costs as a
result of deficient management,
practices, or controls
 Overutilization of services that result
in unnecessary costs to the
Medicaid program
Source: CMS https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/fwa-presentation-handout.pdf

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Definitions of FWA: Abuse
Abuse:
 Provider practices that are inconsistent with sound fiscal,
business, or medical practices, and result in an
unnecessary cost to the Medicaid program, or in
reimbursement for services that are not medically
necessary or that fail to meet professionally recognized
standards for healthcare
 It also includes beneficiary practices that result in
unnecessary cost to the Medicaid program
 To pay for items or services that are billed by mistake by
providers, but should not be paid for by
Medicare/Medicaid
Source: CMS https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/fwa-presentation-handout.pdf

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Examples of Coding and Billing FWA
 Coding
 Unbundling
 Upcoding
 Downcoding
 Billing
 Unnecessary treatments
 Services not rendered
 Duplicate billing resulting in duplicate reimbursement

37. Prepared for THIMA 2018 Annual Meeting Page 36
Healthcare Fraud Impacts EVERYONE
 DOJ recovered $3.7 billion from False Claims Act Cases
in 2017
 Medicare Advantage 2016 improper payment rate was
10% which equals $16.2 billion
https://www.justice.gov/opa/pr/justice-department-recovers-over-37-billion-false-claims-act-cases-fiscal-year-2017
https://www.publicintegrity.org/2017/07/19/21011/fraud-and-billing-mistakes-cost-medicare-and-taxpayers-tens-billions-last-year

38. Prepared for THIMA 2018 Annual Meeting Page 37
False Claims Act
 The FCA has become an important government tool, if
not the most important tool, for demanding healthcare
providers’ compliance with the requirements of the
federal healthcare programs
 Prohibits any person from knowingly presenting or
causing the presentation of a fraudulent claim for
payment
 The False Claims Act, is also known as the “Lincoln
Law”
 Enacted during the Civil War to combat fraud perpetrated by
companies that sold faulty supplies to the Union Army
 Congress passed the statute on March 2, 1863
Source: White Paper. The Supreme Court’s Decision in Universal Health Services v. U.S. ex rel. Escobar: Professor David Freeman Engstrom Answers Critical Legal Questions,
June 17, 2016

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False Claims Act
 Creates liability for anyone who knowingly
submits, uses, or causes to be submitted or
used a false record, statement, or claim for
payment to the government
 Acts in purposeful or deliberate ignorance of
truth or falsity, acts in reckless disregard of
truth or falsity; proof of intent to defraud is
NOT required

40. Prepared for THIMA 2018 Annual Meeting Page 39
False Claims Act
 Medicaid claims are subject to BOTH the Federal FCA
and the FCA in your state
 Patient Protection and Affordable Care Act (PPACA)
added provision that person/organization must report
any overpayments greater than $50 within 60 days of
identification; non-reporting may be considered false
claims and subject to a credible allegation of fraud
referral
 Violations can result in liability for repayment up to
THREE TIMES the original dollar amount and potential
civil penalties of $11,000 for EACH CLAIM

41. Prepared for THIMA 2018 Annual Meeting Page 40
False Claims Act
 FCA contains provision for Whistleblower (i.e., Qui Tam)
Actions
 70% of FCA actions are initiated by whistleblowers
 An individual can file an action on behalf of the
government
 15-25% of recovered claims go to the person who
brought the action (government decides each case)
 Over $3.7 billion has been recovered under FCA in
FY2017
 Whistleblowers:
 46 in 2017 awarded approximately $160 million
https://www.sec.gov/files/sec-2017-annual-report-whistleblower-program.pdf
https://www.justice.gov/opa/pr/justice-department-recovers-over-35-billion-false-claims-act-cases-fiscal-year-2015

42. Non-Physician Provider (NPP) Issues

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Who Can See the NPP?
The questions are:
 Is the payer private, Medicare, or Medicaid?
 Is the patient new or established?
 Is the patient presenting with only established problems
or are any new problems to be addressed?
 Was the service incident-to?
 Where were the services provided?
 Which provider do I bill under?

44. Prepared for THIMA 2018 Annual Meeting Page 43
NPPs – Medicare, Medicaid, Commercial Payers
 Medicare has the most specific guidance for NPP billing
 The information detailed in this presentation is related to
Medicare regulations
 Medicaid has different rules from Medicare when it
comes to NPPs
 Medicaid pays NPPs on a separate fee schedule and has a
separate limitation and coverage book for NPPs
 Follow the requirements set out by private payers; some
payers may defer to state law

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Medicare NPP Reimbursement
What can be reimbursed?
 85% of the physician fee schedule for
services which include independent
medical decision making (MDM)
 100% of the physician fee schedule under
the supervising physician on site for
incident-to service

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Medicare NPP Reimbursement
 General Rule
 Medicare generally requires that the identity of the person who
actually performed the service be reported on the claim
 The Incident-to billing rule is an exception that permits reporting
of services actually performed by one person to be reported
under the name of another, provided that specific and rather
complex requirements are met

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Medicare Incident-To Requirements
 All the following requirements must be met before a NPP
may bill under the incident-to provision:
 The NPP must be an employee of the healthcare organization
 The initial visit (for that condition) must be performed by the physician;
this does not mean that on each occasion of an incidental service
performed by an NPP, that the patient must also see the physician
 There must be direct personal supervision by the physician as an
integral part of the physician's personal in-office service
 The physician must be physically present in the same office suite and
be immediately available to render assistance if that becomes
necessary
 The physician has an active part in the ongoing care of the patient
 Subsequent services by the physician must be of a frequency that
reflects his/her continuing active participation in, and management of,
the course of the treatment

48. Prepared for THIMA 2018 Annual Meeting Page 47
Medicare Incident-To Compliance Issues
 Depending on who actually performed the
service, if incident-to is reported
erroneously, either a 15% or 100%
overpayment could occur
 Person who performed service is unlicensed –
100%
 Person who performed service is licensed
(NP/PA/MD/DO) but is not credentialed in the group
– 100%
 Person who performed service is licensed (NP/PA)
and is credentialed in the group – 15%

49. Prepared for THIMA 2018 Annual Meeting Page 48
Questions?

50. PYA, P.C.
800.270.9629 | www.pyapc.com
Thank you!
Kristen Lilly
MHA, CHC®, CPHQ, RHIA®
PYA
klilly@pyapc.com