The document outlines the Office of Inspector General's (OIG) focus areas for auditing Medicare compliance, including reviewing physicians and suppliers for incorrectly billed amounts, high cumulative payments, physician-owned distributors of spinal implants, place-of-service coding errors, and use of incident-to billing. It then discusses the seven key elements of an effective compliance plan according to OIG: having policies and procedures, designating a compliance officer, conducting training, effective communication, internal monitoring, enforcement, and responding to issues. The presentation emphasizes establishing a culture of compliance, keeping plans up-to-date, ongoing training, investigating reports, and conducting audits.
As the effects of reform continue to implement changes to our nation’s health care structure, providers find themselves forced to act quickly amidst the resultant chaos. Nowhere is the confusion more apparent than when it comes to issues of compliance.
Contact Craig Garner for more information (craig (at) craiggarner (dot) com) or visit
http://craiggarner.com/compliance/.
The Season for Compliance is upon. The Office of the Inspector General has mandated elder care facilities institute this 7 part compliance program. Are you ready?
Office of Civil Rights HIPAA Audits--Ready or Not, Here They ComePYA, P.C.
PYA Compliance Consulting Manager Susan Thomas presented “Office of Civil Rights HIPAA Audits--Ready or Not, Here They Come” at the Kansas Association of Local Health Departments Midyear Meeting.
Learning objectives included:
Understanding the Office of Civil Rights Health Information Technology for Economic and Clinical Health audit program.
Reviewing lessons learned from Phase 1 audits.
Discussing the scope and selection for Phase 2 audits.
Determining Health Insurance Portability and Accountability Act audit readiness.
Reviewing a breach investigation case study.
Considering additional resources.
Onboarding Compliance in the Healthcare Professional EnvironmentEquifax
Healthcare is easily one of the most tightly regulated industries in the US and without a targeted onboarding compliance strategy in place for your Health Care Professional hires (HCP), you could be exposing your organization to significant risks.
Speaking before the Georgia Pediatric Practice Managers Association, PYA Consultant and ICD-10-CM Trainer Kim-Marie Walker addressed recent ICD-10 developments along with basic guidance for the transition, including:
• Comparison of ICD-9 and ICD-10
• ICD-10 organizational and structural differences
• Vendor recommendations and available resources
• Transition planning and roles
As the effects of reform continue to implement changes to our nation’s health care structure, providers find themselves forced to act quickly amidst the resultant chaos. Nowhere is the confusion more apparent than when it comes to issues of compliance.
Contact Craig Garner for more information (craig (at) craiggarner (dot) com) or visit
http://craiggarner.com/compliance/.
The Season for Compliance is upon. The Office of the Inspector General has mandated elder care facilities institute this 7 part compliance program. Are you ready?
Office of Civil Rights HIPAA Audits--Ready or Not, Here They ComePYA, P.C.
PYA Compliance Consulting Manager Susan Thomas presented “Office of Civil Rights HIPAA Audits--Ready or Not, Here They Come” at the Kansas Association of Local Health Departments Midyear Meeting.
Learning objectives included:
Understanding the Office of Civil Rights Health Information Technology for Economic and Clinical Health audit program.
Reviewing lessons learned from Phase 1 audits.
Discussing the scope and selection for Phase 2 audits.
Determining Health Insurance Portability and Accountability Act audit readiness.
Reviewing a breach investigation case study.
Considering additional resources.
Onboarding Compliance in the Healthcare Professional EnvironmentEquifax
Healthcare is easily one of the most tightly regulated industries in the US and without a targeted onboarding compliance strategy in place for your Health Care Professional hires (HCP), you could be exposing your organization to significant risks.
Speaking before the Georgia Pediatric Practice Managers Association, PYA Consultant and ICD-10-CM Trainer Kim-Marie Walker addressed recent ICD-10 developments along with basic guidance for the transition, including:
• Comparison of ICD-9 and ICD-10
• ICD-10 organizational and structural differences
• Vendor recommendations and available resources
• Transition planning and roles
This presentation covers the basics of Healthcare domain and the testing challenges faced there off.Good content for people having interest or working in Health Care domain.
Big Data: Implications of Data Mining for Employed Physician Compliance Manag...PYA, P.C.
PYA Consulting Manager Kristen Lilly presented “Big Data: Implications of Data Mining for Employed Physician Compliance Management” during a webinar for the Georgia chapter of the Healthcare Financial Management Association (Georgia HFMA), March 31, 2016.
The presentation explored:
Public relations and litigation risk from the public dissemination of data by the government.
Internal use of broad spectrum analytics in employed physician compliance management.
Determination of risk tolerance and the customization of “outside the box” analytics.
Benchmarking, monitoring, and defining physician-focused risk area reviews.
Revenue Cycle Management: Market Dynamics & Opportunities in a Changing Healt...Cognizant
Sourcing revenue cycle management can help healthcare insurers overcome growing reimbursement complexities. Yet providers say managing dozens of RCM vendors comes with its own complications. That’s why they’re increasingly sourcing comprehensive RCM solutions with a single vendor to generate greater efficiencies, reduce costs and improve patient satisfaction.
Presentation from California Homecare Association 2013 Annual event. Technology brings additional resources to the fingertips of nurses and homecare professionals at the frontline to support their clinical decision-making and contribute to improved client outcomes. With day to day changing patient needs, there is increasing evidence that technology and applications will transform the industry and facilitate faster and better communications, prevent fraud, and proactively manage compliance requirements.
With all the agencies out there whose purpose it is to review, audit, evaluate, assess and, if called for, prosecute providers who are not in "compliance", the likelihood having one of them scrutinize your work has never been higher. So, with all the added activity by these agencies, how prepared are you to know how to handle an audit notice from one of them?
ICD-10 Transition: What Health Lawyers Need to KnowPYA, P.C.
PYA Principal Denise Hall, along with Senior Corporate Counsel Julie Chicoine of Ohio State University Wexner Medical Center, presented “ICD-10 Transition: What Health Lawyers Need to Know” at the AHLA 2015 Institute on Medicare and Medicaid Payment Issues.
This New York Medicaid Nursing Facility Case Mix Seminar discusses the necessary documentation needed to support the assigned Medicaid RUG to ensure accurate reimbursement for care provided. New York OMIG Auditors are focused on auditing "high risk" Medicaid Case Mix MDSs for Nursing Facilities with a change in CMI by more than five percent for 2012.
1. Learn to identify the specific components of NY RUG-III 53 categories.
2. Learn to identify high risk NY RUG-III 53 categories.
3. Learn to identify documentation requirements to support the RUG components.
4. Learn to identify strategies for organization of the Medical Record in preparation for OMIG Audits.
Coordination of Benefits and its implications to Health PlansCitiusTech
Coordination of Benefits (COB) allows plans that provide health and/or prescription coverage with Medicare to determine their respective payment responsibilities (i.e. determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan). Member’s primary plan has the responsibility of paying claims first, followed by coverage by remaining plans. This process of splitting the costs across multiple coverage is called COB. This document introduces COB and how health plans and members benefit through COB regulations.
Regulatory Compliance, Risk Management, and the Trustee's RolePYA, P.C.
PYA Principal Shannon Sumner and Consulting Manager Susan Thomas presented “Regulatory Compliance, Risk Management, and the Trustee’s Role.” In this presentation, they will:
Describe the evolving compliance and risk management landscape, including government agencies’ expectations for compliance oversight. This presentation will:
- Outline recent government investigations and settlements.
- Provide key takeaways regarding responsibilities for ensuring an effective compliance program.
- Connect trustee duties to specific elements of enterprise risk management.
- Empower trustees with questions to ask leadership teams in preparation for playing a more active role in the compliance program.
This presentation covers the basics of Healthcare domain and the testing challenges faced there off.Good content for people having interest or working in Health Care domain.
Big Data: Implications of Data Mining for Employed Physician Compliance Manag...PYA, P.C.
PYA Consulting Manager Kristen Lilly presented “Big Data: Implications of Data Mining for Employed Physician Compliance Management” during a webinar for the Georgia chapter of the Healthcare Financial Management Association (Georgia HFMA), March 31, 2016.
The presentation explored:
Public relations and litigation risk from the public dissemination of data by the government.
Internal use of broad spectrum analytics in employed physician compliance management.
Determination of risk tolerance and the customization of “outside the box” analytics.
Benchmarking, monitoring, and defining physician-focused risk area reviews.
Revenue Cycle Management: Market Dynamics & Opportunities in a Changing Healt...Cognizant
Sourcing revenue cycle management can help healthcare insurers overcome growing reimbursement complexities. Yet providers say managing dozens of RCM vendors comes with its own complications. That’s why they’re increasingly sourcing comprehensive RCM solutions with a single vendor to generate greater efficiencies, reduce costs and improve patient satisfaction.
Presentation from California Homecare Association 2013 Annual event. Technology brings additional resources to the fingertips of nurses and homecare professionals at the frontline to support their clinical decision-making and contribute to improved client outcomes. With day to day changing patient needs, there is increasing evidence that technology and applications will transform the industry and facilitate faster and better communications, prevent fraud, and proactively manage compliance requirements.
With all the agencies out there whose purpose it is to review, audit, evaluate, assess and, if called for, prosecute providers who are not in "compliance", the likelihood having one of them scrutinize your work has never been higher. So, with all the added activity by these agencies, how prepared are you to know how to handle an audit notice from one of them?
ICD-10 Transition: What Health Lawyers Need to KnowPYA, P.C.
PYA Principal Denise Hall, along with Senior Corporate Counsel Julie Chicoine of Ohio State University Wexner Medical Center, presented “ICD-10 Transition: What Health Lawyers Need to Know” at the AHLA 2015 Institute on Medicare and Medicaid Payment Issues.
This New York Medicaid Nursing Facility Case Mix Seminar discusses the necessary documentation needed to support the assigned Medicaid RUG to ensure accurate reimbursement for care provided. New York OMIG Auditors are focused on auditing "high risk" Medicaid Case Mix MDSs for Nursing Facilities with a change in CMI by more than five percent for 2012.
1. Learn to identify the specific components of NY RUG-III 53 categories.
2. Learn to identify high risk NY RUG-III 53 categories.
3. Learn to identify documentation requirements to support the RUG components.
4. Learn to identify strategies for organization of the Medical Record in preparation for OMIG Audits.
Coordination of Benefits and its implications to Health PlansCitiusTech
Coordination of Benefits (COB) allows plans that provide health and/or prescription coverage with Medicare to determine their respective payment responsibilities (i.e. determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan). Member’s primary plan has the responsibility of paying claims first, followed by coverage by remaining plans. This process of splitting the costs across multiple coverage is called COB. This document introduces COB and how health plans and members benefit through COB regulations.
Regulatory Compliance, Risk Management, and the Trustee's RolePYA, P.C.
PYA Principal Shannon Sumner and Consulting Manager Susan Thomas presented “Regulatory Compliance, Risk Management, and the Trustee’s Role.” In this presentation, they will:
Describe the evolving compliance and risk management landscape, including government agencies’ expectations for compliance oversight. This presentation will:
- Outline recent government investigations and settlements.
- Provide key takeaways regarding responsibilities for ensuring an effective compliance program.
- Connect trustee duties to specific elements of enterprise risk management.
- Empower trustees with questions to ask leadership teams in preparation for playing a more active role in the compliance program.
Efficient Internal Medicine Billing Services for Your Practice.edited (1).docxCures MB
Discover how efficient internal medicine billing services can streamline your practice's revenue cycle. Learn about the benefits and best practices for implementing these services.
Efficient internal medicine billing services are essential for medical practices to ensure accurate and timely reimbursement. From managing patient accounts to submitting claims to insurance companies, internal medicine billing plays a crucial role in the financial health of a practice. This guide will explore the importance of efficient internal medicine billing services and how they can benefit your practice.
Let's define internal medicine billing and its role in the healthcare industry. Internal medicine billing refers to submitting and following up on claims for services provided by internal medicine physicians. This includes office visits, consultations, procedures, and other medical services. Internal medicine billing requires a thorough understanding of medical coding and billing practices, as well as knowledge of insurance guidelines and regulations.
US Medical Billing A Comprehensive Overview for Healthcare Providers.pdfmedquikhelathsolutio
The intricate world of medical billing can feel like a labyrinth for healthcare providers. Between deciphering complex medical codes, navigating insurance regulations, and ensuring timely reimbursements, it's easy to get overwhelmed.
Top Goals for Physicians to Implement In Their Facility.pptxalicecarlos1
Let's understand how our medical billing and coding experts help with Top Goals for Physicians to Implement In Their Facilities.
Read More: https://bit.ly/3LFPThv
Medical groups and individual practices in Georgia that struggle managing denials or write off denied claims as bad debts can now handle denial with the help of these strategies.
Compliance and Legal Risks in Laborist, Surgicalist, and Hospitalist Arrangem...MD Ranger, Inc.
Have you structured your hospital-based physician contracts to address all aspects of compliance?
Hospitalist agreements involve unique compliance and financial issues, particularly when global payments and advanced practice providers are involved. Risks include indirect compensation, billing and other compliance issues. This presentation will discuss compliance risks and provide guidance on how to structure compliant contracts and business arrangements.
Meaningful Use Audits and healthcare compliance course offered to Physicians and healthcare professionals to explain the basics of Meaningful Use and HITECH audits. Course is general in nature as many Physicians and organizations are in different stages of meaningful use.
Advertising AssignmentPick a global product brand and co.docxstandfordabbot
Advertising Assignment
Pick a global product / brand and country of interest to you (Do not choose South
Korea). In a 2-page report (double space), compare and contrast how that offering is
advertised in the USA and the foreign market. Please provide your thoughts pro and
con and any questions you have about the differences in marketing practice, as well as
any suggestions / recommendations for potentially doing things better. Source material
for this assignment can be obtained from an internet search and published journal
articles. Please provide a bibliographic list of your references at the back of your paper.
MLA Format.
Please reply to
William Polanco- Rowland–
Please note minimum of 200 words. Please cite one scholarly source. In-text citation should be included.
The cost of healthcare and the associated dollar signs connected to it has kept a certain number of patients away from seeing a doctor when needed. The creation of Managed Care Organizations exists to deal with the exorbitant prices associated with seeing a healthcare provider and actually decreasing costs while increasing the level of care (Nikitas et al, 2020). The common thread is the network of providers that exists within each network that agrees to provide care for the policy holders for an agreed price. Among the Managed Care Organizations are three plans known as Health Maintenance Organization (HMO’s), Preferred Provider Organization(PPO’s), and Point-Of-Service Plan (POS). The structure of HMO’s exists as a network of hospitals, doctors and providers that usually only pay for care in the network visits. These have lower premiums the insured must use a provider within the network that is their Primary Care Physician (PCP). In addition, referrals must be obtained from the PCPs for visits to specialists within the network (healthy.kaiserpermanente.org, 2022) Membership is generally required in the form of employment or one who lives in the area of coverage. With an associated higher cost is the PPO’s. They will allow for visits to in or out of network providers as well as cost of fee coverage for visiting those out of network providers, generally covered by the increased monthly premiums and out of pocket costs (healthy.kaiserpermanente.org, 2022). The third plan being mentioned here is the Point-Of-Service Plan (POS). This is considered a hybrid of plans which allows for the insured to make decisions to see who they want as a provider without first obtaining prior approval. With regard to a plan that works best for the consumer, the HMO plan is one where the nurse within the system is most connected to the providers and the case files allowing for a seamless connection with provider to facility. The other two plans have steps between each provider and information can be lost in the shuffle. The position of nurses working within the healthcare system allows them an opportunity to help keep health costs down via means of self aud.
Navigating Dermatology Billing Common Mistakes and Best PracticesRM Healthcare
Explore the intricacies of dermatology billing in the United States with our comprehensive article, "Navigating Dermatology Billing: Common Mistakes and Best Practices." Dive into the world of dermatology billing services and discover the most prevalent mistakes that can impact your practice's financial health. Learn about the best practices and strategies to avoid these pitfalls, ensuring efficient and compliant dermatology billing processes. Whether you're a dermatologist seeking to enhance your billing practices or interested in the nuances of US medical billing, this article provides valuable insights to help you navigate this complex terrain effectively.
Mastering Ambulatory Surgery Center Billing_ Essential Guidelines for Success...Cosentus
In this article, we’ll cover everything you need to know about ambulatory surgery center billing and what makes it so complex. We’ll also look at some of the issues that arise around the billing process, as well as some industry best practices and ambulatory surgery center billing guidelines you can adopt to ensure your business doesn’t face any hiccups on account of ambulatory surgery center billing.
Mastering Pharmacy Medical Billing + Claims Submissionkendall100
Claim your free access to invaluable pharmacy billing guides and streamline your processes with confidence. Pharmacy billing encompasses submitting claims to insurance payers for reimbursement for pharmacy services. These services range from dispensing medications to providing medication therapy management (MTM) and other clinical interventions you can bill for!
Similar to Developing a Practice Compliance Plan (20)
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
3. OIG
Physicians and Suppliers: Compliance
With Assignment Rules
Reviewing for Inappropriately billed in excess
of amounts allowed by Medicare and to
assess beneficiaries’ awareness of their rights
and responsibilities regarding potential billing
violations and Medicare coverage guidelines.
4. OIG
Physicians and Other Suppliers: High
Cumulative Part B Payments
Reviewing for a high cumulative payment defined as
an unusually high payment made to an individual
physician or supplier, or on behalf of an individual
beneficiary, over a specified period. Prior OIG work
has shown that unusually high Medicare payments
may indicate incorrect billing or fraud and abuse.
5. OIG
Physician-Owned Distributors of Spinal
Implants
Reviewing to what extent to which physician-owned
distributors (POD) provide spinal implants
purchased by hospitals and analyzing Medicare
claims data to determine whether PODs that have
been identified in review are associated with high
use of spinal implants. Congress has expressed
concern that PODs could create conflicts of interest
and safety concerns for patients.
6. OIG
Physicians: Place-of-Service Errors
Reviewing physicians’ coding on Medicare Part B
claims for services performed in ambulatory surgical
centers and hospital outpatient departments to
determine whether they properly coded the places of
service. Federal regulations provide for different
levels of payments to physicians depending on
where services are performed.
7. OIG
Physicians: Incident-To Services
Medicare Part B pays for certain services billed by
physicians that are performed by non-physicians
incident to a physician office visit. A 2009 OIG
review found that when Medicare allowed
physicians’ billings for more than 24 hours of
services in a day, half of the services were not
performed by a physician. We also found that
unqualified non-physicians performed 21 percent of
the services that physicians did not perform
personally.
8. OIG
Physicians: Impact of Opting Out of Medicare
Reviewing the extent to which physicians are opting
out of Medicare and determining whether physicians
who have opted out, are permitted to enter into
private contracts with Medicare beneficiaries.
As a result of entering into private contracts,
physicians must commit that they will not submit a
claim to Medicare for any Medicare beneficiary.
9. OIG
Chiropractors: Part B Payments for Services
Reviewing Medicare Part B payments for
chiropractic services to determine whether such
payments were in accordance with Medicare
requirements. Medicare chiropractors’ services
include only treatment by means of manual
manipulation of the spine. Chiropractic maintenance
therapy is not considered to be medically reasonable
or necessary and is therefore not payable.
10. OIG
Evaluation and Management Services: Use of Modifiers
During the Global Surgery Period
Reviewing the appropriateness of the use of certain claims
modifier codes during the global surgery period to determine
whether Medicare payments for claims with modifiers used
during the global surgery period were in accordance with
Medicare requirements.
The global surgery payment includes a surgical service and
related preoperative and postoperative E/M services
provided during the global surgery period.
11. Steps to a Compliance Plan
The OIG has established a list of
Seven key elements when
establishing your Compliance
plan.
22. False Claims Act
This act addresses any entity who
submits or causes to be submitted a claim
for services that are:
Not rendered
Miscoded
Already covered under another claim
Not supported in the medical record
Violates Stark Law
23. Penalties
If a claim is submitted by an individual
who "knows or should know“ (termed
deliberate ignorance) that they are filing
a false claim, civil sanctions may be
imposed.
24. Penalties
Civil sanctions may be as much as $11,000
per claim ($50,000 for an anti-kickback
violation) plus an assessment of up to three
times the amount improperly claimed.
Each claim for payment could cause a
separate penalty.
25. Qui Tam Suits
Whistle blower suits pay 30% of the
recovered amount. Who are known
whistleblowers:
Patients
Patients family members
Competitors
Past and Present Employees
Ex-Business Partners
26. Code of Conduct
Each compliance plan should begin with a
code of conduct.
All employees, physicians, and any member of
practice oversight should be educated. As a
record of education you should have a signed
copy of acknowledgement on file.
28. Training
Annual training should be conducted on
all areas of compliance and a record of
attendance should be kept and readily
available.
29. Ongoing Training
Keep up with changes and communicate with
all staff
New Employees need intense training and all
employees need refreshers
Make sure all training complies with state and
federal regulations.
30. Ongoing Training
Be sure that all employees know the
compliance plan, as well as, who should be
notified when an issue arrives.
If you are the compliance professional: Be
approachable and always have a no retaliation
policy.
31. Follow-up on Reports
Conduct investigation
Document the areas of concern and
how the issue was resolved
Self report, when necessary
32. Policies to Keep in Mind
Patient Discounts
Routine Waiver of Co-pays/Deductibles
Attempt to collect policy
Bad debt write-offs
Discounts and processional courtesies
35. Policies…
Documentation Guidelines
1995 and 1997
Proper Documentation for
Consultations
Global and Bundled Services
Care Plan Oversight
Screening Services
37. Audit Program
Establish a realistic audit schedule
Decide if all audits will be done in-house, if
you will seek outside help, or will use a
combination of both
Decide if you need additional auditing or
training based on what you discover
Self report on your findings
Implement corrective action to promote
compliance
38. Audit Program
Random sample vs targeted
Sample all types of service provided
Review the encounter form (charge ticket)
and EOB in addition to the medical record.
This will help you locate missed charges or
inappropriate payments.
Take the opportunity to begin proactive
education approach to ICD-10