This document summarizes the key challenges and regulatory environment facing ambulance providers. It notes the increased government scrutiny of non-emergency ambulance transports, especially repetitive transports. It recommends steps compliance officers can take to strengthen their programs, such as implementing screening of repetitive patients and robust documentation standards. A recent ambulance-focused Corporate Integrity Agreement added new, industry-specific provisions regarding coding certification, medical director requirements, and vehicle maintenance, showing the heightened focus on this industry. Overall, the document advises ambulance providers to re-examine their operations and compliance programs to ensure robust policies and procedures are in place to navigate intensified government oversight.

1. 27
OIG 2015
Work Plan, Part 1:
Do fewer projects
mean a sharper
focus?
Nathaniel Lacktman
35
Medicare claims
appeals process: Newly
announced alternatives
to ALJ hearings
Jessica C. Forster and
Kevin R. Miserez
47
Comparative
billing reports
support
auditing efforts
Kimberly Hrehor and
Dan McCullough
39
OCR enforcement:
Lessons learned
and
preparing for
what’s ahead
Betta Sherman
a publication of the health care compliance association www.hcca-info.org
ComplianceTODAY January 2015
Holding the compass of compliance
in nine states — and across the world
an interview with Ruth Krueger
Enterprise Compliance Program Manager, Sanford Health
See page 20
This article, published in Compliance Today, appears here with permission from the Health Care Compliance Association. Call HCCA at 888-580-8373 with reprint requests.

2. 888-580-8373 www.hcca-info.org 69
ComplianceToday January2015
Wallace
T
he healthcare industry as a whole
has seen the increase of government
enforcement actions with respect to
billing federal and state healthcare programs.
Compliance officers have to be prepared to
have their operations audited or investigated
by a spectrum of government con-
tractors and agencies, including the
Office of Inspector General (OIG),
Department of Justice (DOJ), Zone
Program Integrity Contractors (ZPICs),
or Recovery Audit Contractors (RACs),
to name a few. With the recent pub-
lication of a report titled “Medicare
Provider Utilization and Payment
Data: Physician and Other Supplier” there
has been increased scrutiny placed on those
providers that obtained higher Medicare reim-
bursement when compared to other providers
on the list. Specifically, ambulance providers
have been the target of media coverage regard-
ing their disproportionately higher Medicare
reimbursement. With this increased attention,
the ambulance industry and its compliance
officers have felt the pressure of the elevated
targeting by the OIG, DOJ, and ZPICs.
This article surveys the current regulatory
environment of the ambulance industry, and
provides a road map to assist compliance
officers in building effective compliance
solutions that will allow them to navigate
through the various government requirements
and enforcement activities.
Background:
Medicare requirements for ambulance coverage
Pursuant to the Medicare Benefit Policy Manual,
Chapter 10,1
for an ambulance transport to be
covered, the transport must be medically nec-
essary and reasonable. Medical necessity for
ambulance transportation is established when
the patient’s condition is such that use of any
other method of transportation (i.e., wheelchair
or gurney van, family vehicle, taxi, etc.) is con-
traindicated. CMS goes on to state that in any
case in which some means of transportation
other than an ambulance could be used without
endangering the individual’s health, whether or
by Jason P. Wallace, JD, MPH, CAC
Ambulance industry:
Guidance for intensified
government oversight
»» The recent publication of the Medicare Provider Utilization and Payment Data has placed increased focus on the ambulance industry.
»» Non-emergency ambulance transportation providers are most at risk for government enforcement.
»» OIG Update: A recent ambulance provider Corporate Integrity Agreement adds ambulance industry-specific language.
»» Compliance officers need to reexamine the current regulatory environment to ensure their operations remain in compliance.
»» Compliance officers may have trouble convincing ambulance providers to spend the time and resources necessary to develop truly
effective compliance programs.
Jason P. Wallace (jason.p.wallace@us.pwc.com) is a Manager in the Performance,
Governance, Risk Compliance practice with PricewaterhouseCoopers, LLP in
New York City. bit.ly/in-JasonWallace

3. 888-580-8373 www.hcca-info.org 71
ComplianceToday January2015
not such other transportation is actually avail-
able, no payment may be made for ambulance
services. Additionally, the mere presence of a
physician’s order for transport by ambulance
does not necessarily prove or disprove whether
the transport was medically necessary.
This medical necessity requirement must
be satisfied for each of the ambulance trans-
ports that an ambulance provider bills to the
Medicare program for reimbursement. The
documentation that provides the strongest sup-
port to establishing medical necessity is the
patient care report (PCR), which is essentially
a medical record documented by the treating
emergency medical technician (EMT) or other
provider, detailing the patient’s condition and
interventions performed during the transport.
As demonstrated by recent enforcement actions
of the OIG and DOJ, if an ambulance provider
bills Medicare for transports where the patient’s
condition does not meet medical necessity, that
provider could be liable and be subjected to the
applicable fines, administrative sanctions, and
possible prison time. In addition to the medical
necessity requirement, ambulance providers
must ensure that transports billed to Medicare
meet certain “origin” and “destination” param-
eters, have physician certification statements on
file, and are coded with the correct level of ser-
vice provided. Any misstep during this process
could lead the ambulance provider down the
path of Medicare overpayments, as well as civil
and criminal liability.
Government emphasis
on non-emergency transports
When you ask most people what an ambu-
lance provider does, the response is usually
something like “They respond to 911 calls
to transport injured and dying patients to
an emergency department.” Although emer-
gency transportation is a large part of what
ambulance providers render, they also provide
non-emergency transportation services. These
non-emergency services are often referred
to as inter-facility transports (IFT) because
they are almost always originating at one
health facility and ending at another destina-
tion health facility (i.e., hospital to a skilled
nursing facility).
The non-emergency side of the ambu-
lance transport industry is most subject to
government scrutiny and enforcement efforts.
Specifically, the government has been target-
ing ambulance companies that provide large
amounts of scheduled non-emergency repeti-
tive transports. A repetitive ambulance service
is defined as ambulance transportation that
is furnished three or more times during a
10-day period or at least once per week for at
least three weeks. Often the patients requiring
this type of service are being transported to
receive dialysis or radiation treatment.
Examples of the type of government action
taken regarding repetitive transports are:
(1) On October 1, 2013, as part of the American
Taxpayer Relief Act of 2012, the government
instituted a 10% reduction in reimbursement
rates for ambulance transports to or from a
dialysis center; and (2) Implementation of a
prior authorization demonstration program
for repetitive-scheduled, non-emergent ambu-
lance transport in New Jersey, Pennsylvania,
and South Carolina. Given the increased
oversight of repetitive patient transports,
compliance officers need to place this risk at
the top of their mitigation strategy.
Compliance officers must work hand-
in-hand with operations management and
Quality to develop a robust repetitive patient
screening and monitoring program. The basic
elements of such a program would include:
·· Training the communications personnel
(i.e., call intake, dispatch) on identifying
Medicare repetitive patient transports
when the scheduling requests are received;
·· Implementing an initial dispatch triage pro-
cess that serves as a mitigating screening

4. 72 www.hcca-info.org 888-580-8373
ComplianceToday January2015
tool. This triage process would be used to
evaluate the patient’s condition and make
an initial determination of whether or not
the patient meets the CMS definition of
medical necessity (as described above);
·· Appointing an individual with a clinical
background (ideally a registered nurse,
but at least a paramedic) to conduct a pre-
transport on-site evaluation of the patient
where they reside. This evaluation must
be extremely detailed and include infor-
mation on where the patient currently
resides (e.g., private residence, skilled nurs-
ing home, assisted living facility etc.); the
patient’s personal and insurance informa-
tion; information on the type and location
of the destination facility; and information
on the type of treatment the patient will
be receiving at the transport destination.
Evaluation of the patient’s condition should
include answering questions, such as: Does
patient’s condition require transportation
by ambulance and contraindicate all other
modes of transportation? How is the patient
transported to other locations and appoint-
ments? Can the patient tolerate sitting in
a wheelchair during transport? Can the
patient ambulate (i.e., with or without assis-
tance)? Does the patient have any durable
medical equipment that he/she utilizes?
Does the patient have any decubitus ulcers
(note location and stage)? Does the patient
have any contractures (note location and
severity)? Is the patient bed confined (i.e.,
unable to ambulate, unable to get up from
bed without assistance, and unable to sit in
a chair or wheelchair)?
·· Having the appointed clinical evaluator
continually (i.e., every 30 days) conduct a
short-form re-evaluation of the patient to
ensure their condition continues to meet
medical necessity.
·· Having the compliance officer continually
audit and monitor the repetitive patients
who are being transported by the ambu-
lance provider. This involves keeping and
maintaining an accurate list or database of
all current repetitive transport patients; and
conducting audits and reviews on samples
of the repetitive transport patients’ PCRs
to ensure: (1) the condition meets medical
necessity, and (2) the field crew providers
are demonstrating proper documentation
skills and practices.
With a program like this in place, a com-
pliance officer can be properly equipped with
robust supporting documentation when a
government auditor or investigator comes
knocking at the door.
Comments regarding ambulance providers
·· According to the Government Account­
ability Office (GAO), the number of
Basic Life Support (BLS) non-emergent
transports for Medicare fee-for-service bene-
ficiaries increased by 59% from 2004 to 2010.2
·· The Department of Health and Human
Services Office of Inspector General
(OIG) has published numerous reports
about Medicare’s ambulance benefit and
has concluded that this benefit is highly
vulnerable to abuse. A 2006 OIG study,3
evaluated the appropriate use of the ambu-
lance benefit. The findings indicated a 20%
nationwide improper payment for non-
emergent ambulance transports, meaning
that 20% of non-emergent transports did
not meet Medicare’s coverage require-
ments (i.e., medical necessity). This report
recommended that CMS implement activi-
ties to reduce these improper payments.
·· In June 2013, the Medicare Payment
Advisory Commission (MedPAC) pub-
lished a report4
that included an analysis
of non-emergent ambulance transports to
dialysis facilities. The report stated that
transports to and from dialysis facilities

5. 888-580-8373 www.hcca-info.org 73
ComplianceToday January2015
have grown noticeably in recent years and
represent a large share of non-emergent
ambulance claims. In the five-year period
between 2007 and 2011, the volume of
transports to and from a dialysis facility
increased 20%, more than twice the rate of
all other ambulance transports combined.
In 2011, ambulance transports to and from
dialysis facilities accounted for nearly $700
million in Medicare spending, or approxi-
mately 13% of Medicare expenditures on
ambulance services.
New ambulance-focused
corporate integrity agreement
Upon review of a recent ambulance provider
Corporate Integrity Agreement (CIA),5
you
will find many new provisions have been
added that relate directly to the ambulance
industry. This demonstrates the government’s
willingness to invest the time and money
to learn more about this industry in order
help mitigate what is perceived as a source of
Medicare billing fraud and abuse.
Some examples of the new provisions in
this CIA are:
·· “Relevant Covered Persons” includes
Covered Persons who are involved in the
provision of ambulance transportation
services (and/or documentation of such
services) or who perform, manage, review,
or supervise dispatch, billing, claims, or
coding functions on behalf of Provider.
·· …ensuring proper and accurate documen-
tation in the dispatch, transport, billing,
coding, and reimbursement process
·· …tracking licensure and maintenance of
all transport vehicles…
·· Ambulance Coder Certification. Within 120
days after the Effective Date, Provider will
establish requirements for personnel who
code and will maintain those requirements,
as described in this paragraph, for the term
of the CIA. In addition to receiving the
General and Specific Training described
above, each coding professional shall attain
a nationally recognized ambulance billing
and coding certification within 120 days of
the Effective Date.
·· Medical Director Certification. Within 120
days after the Effective Date, Provider
will establish requirements for Medical
Directors and will maintain those require-
ments, as described in this paragraph, for
the term of the CIA. A Medical Director
must be a physician who is experienced
in treating trauma patients and main-
tains appropriate nationally-recognized
accreditation/licensing in this practice
of medicine. In addition to receiving the
General and Specific Training described
above, each Medical Director shall attain
within 120 days of the Effective Date, a
nationally recognized Emergency Medical
Services Certification. This Certification
requirement must be obtained through a
source that is specifically and previously
approved by the OIG under this CIA.
·· Maintaining license and certification require-
ments. All professionals, including doctors,
EMTs, Paramedics, and Ambulance driv-
ers, must maintain their licenses and meet
state and local requirements for certifica-
tion and/or licensure.
·· Maintaining Vehicle Requirements. All vehi-
cles used to transport patients must be,
at all times, properly licensed and main-
tained in accordance with all applicable
state, local, and federal requirements.
The use of industry-specific language in
the CIA (which have historically been very
broad templates), in my opinion, indicates
that the OIG is placing an enhanced emphasis
on ambulance providers. Thus, ambulance
providers should take a hard look at their
operations and see what is needed to get their
billing integrity and compliance practices in

6. 888-580-8373 www.hcca-info.org 75
ComplianceToday January2015
order. The remainder of the article will cover
recommendations for building an effective
compliance program for ambulance providers.
Implementation of an
ambulance provider compliance program
Most providers are now aware of the OIG’s
seven recommended elements of an effective
compliance program. I will go through each
element and provide some insight into what
ambulance provider compliance officers can
do to satisfy these requirements.
1. Implementing written policies and
procedures and standards of conduct
Today if all ambulance providers were asked if
they had compliance policies and procedures,
a majority of them would say yes. However,
most if not all of those providers could not
demonstrate their policies’ effectiveness or
the necessary dissemination to the staff.
Ambulance providers that are just starting
to initiate compliance efforts also have a ten-
dency to place minimal investment or support
into their compliance functions and usually
use “boilerplate” programs that are available
through various sources. The worn-out line
that states “It is not enough to have a policy
and procedure collecting dust on a shelf” is
nevertheless still true. In order for the poli-
cies and procedures to be effective, they must
be tailored to the operations of the provider
and be supported by a tone from the top-level
management that permeates throughout the
organization. In order to achieve success in this
element, the provider must take compliance
seriously, provide adequate economic support,
and invest the time necessary to develop truly
effective policies and procedures.
The best way for compliance officers to get
started is to educate top-level management and
gain appropriate stakeholder buy-in. I know
there will be compliance officers out there read-
ing this article, saying that this is “easier said
than done.” As a previous compliance officer
for an ambulance provider, I absolutely agree
that this is no easy task in the EMS industry.
There will no doubt be conflicts with various
personalities and egos in operational manage-
ment, and some, if not most of them, will be
skeptical of any change. However, this is where
it is the compliance officer’s duty to not only
be knowledgeable of the relevant regulations
and guidance, but also find ways to make these
compliance risks “real” for operational manage-
ment. Compliance officers should present the
recent enforcement actions and cases brought
against ambulance providers for non-compli-
ance. They should demonstrate how these types
of scenarios can be devastating for the economic
status and reputation of the organization.
Lastly, compliance officers must emphasize that
having effective compliance processes in place
not only mitigates risks, but also enhances the
organization’s performance. Compliance is not
just about abiding by rules and regulations; it
also involves setting up best practices in patient
care documentation, billing, and quality of care.
Once you have adequately made the connection
between compliance and the organization’s per-
formance, you will be speaking the language of
the operational management.
2. Designating a compliance officer
and compliance committee
In my experience, when ambulance providers
initiate a compliance program and designate a
compliance officer, it is rarely a ”management
level” employee with appropriate credentials.
Quite often, the provider will simply ask the
clinical quality officer or risk manager to take
on the additional compliance role. These indi-
viduals often lack any compliance training
or knowledge, and they are not adequately
motivated by management to ensure that
compliance functions are a major focus. When
I review the training or audits that are con-
ducted by these compliance designees, the

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ComplianceToday January2015
focus is usually on clinical interventions or
outcomes, which represents the background
and training of these individuals. Little if
any emphasis is placed on billing integrity,
documentation of medical necessity, contract-
ing, or healthcare fraud and abuse laws. To
have an effective compliance program, the
ambulance provider must appoint a compli-
ance officer who can be a champion for these
specific areas. This position can be outsourced,
if necessary, to obtain an individual with
the appropriate credentials and background.
However, the outsourced compliance repre-
sentative must be able to demonstrate that the
proper time and effort was spend on the oper-
ation’s compliance program and functions.
When creating the compliance officer
position, the provider must also address orga-
nizational structure and reporting issues.
Compliance officers should be part of the top-
level management team and be empowered to
do their jobs. Compliance officers should have
direct access to the CEO and board of direc-
tors when reporting on compliance concerns.
Providers should avoid setting up a structure
in which the compliance officer reports to the
general counsel, CFO, or other operational
management regarding compliance matters.
The government has repeatedly held the posi-
tion that such arrangements contain inherent
conflicts of interest that will affect the compli-
ance program’s performance.
As for compliance committees, it is quite
rare to find any ambulance providers with
formalized compliance committees in place.
This is concerning, given how valuable these
committees can be in terms of focusing compli-
ance efforts, gaining stakeholder support, and
sharing experiences between different opera-
tion localities. Having a compliance committee
in place demonstrates to auditors, investigators,
and contractors that a high priority is placed
on compliance within the provider’s busi-
ness operations. The compliance committee
members should be appointed by the board
of directors, with the compliance officer as the
committee chair. Compliance officers can best
use the compliance committee by educating the
board of directors on compliance issues, what
the Compliance department is assessing, and
the board’s responsibilities regarding compli-
ance. This board education will enhance the
organization’s compliance culture by making it
a priority and concern at the top level.
3. Conducting effective
training and education
Effective training and education is one of
the most important elements of a compli-
ance program, because this is what brings the
program to life and puts policies and proce-
dures into practice. This element takes your
program from one that is simply a “compli-
ance book” collecting dust, to something that
becomes the culture of the organization. This
culture of compliance is what every health
provider should strive for when implement-
ing a compliance program. The specific topics
that should be covered as part of the compli-
ance training and education include but are
not limited to: (1) documentation of medical
necessity; (2) policy regarding documenta-
tion coaching or third-party PCR alterations;
(3) general billing processes; (4) facility
contracting and the Anti-Kickback Statute;
(5) implementing dispatch triage processes;
(6) False Claims Act and fraud and abuse laws;
(7) HIPAA/HITECH; (8) compliance issue
reporting and policy of non-retaliation.
In the world of EMS, the compliance
officer must take into account the audience
to which he/she is presenting. It is often the
case that the audience in an EMS onboarding
class has an average age of 22 or 23, so getting
your message across in a way that resonates
with your listeners can be a challenge. An
important tenant of training is that if you can’t
explain an issue in way that your audience can

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ComplianceToday January2015
understand, then you don’t know the mate-
rial well enough. The compliance officer must
know the presentation material so well that
he/she can explain the issues to a wide variety
of audiences, including the board, manage-
ment, and new EMTs. The compliance training
should always end with a questionnaire that
tests the audience’s knowledge of the material.
This tool will also gauge how well the compli-
ance officer has presented the material and if
the message was adequately received.
4. Developing effective
lines of communication
Every healthcare provider, including ambulance
providers, should have a mechanism by which
its employees can submit good-faith reports of
compliance violations. These compliance hot-
lines can be internal numbers that are overseen
by the compliance officer, or outsourced to a
hotline vendor. In any case, all the reports must
be investigated, and documentation of the inves-
tigation should be kept on file. The employees of
the organization should be aware of the hotline
number and the provider’s zero-tolerance policy
regarding retaliation for good-faith reporting of
compliance issues. Without this mechanism in
place, the lines of communication and reporting
will never be truly open and effective.
Compliance officers can engage outside
vendors that operate compliance hotlines, or
they can operate and maintain the hotline
themselves. In either case, the compliance
officer is responsible to ensure that all tips
and reports received through hotline are fully
investigated. These investigations should be
well documented, and feedback on the resolu-
tion of the issue should be communicated to
the reporting individual.
5. Conducting internal
auditing and monitoring
The compliance officer is responsible for con-
ducting continuous auditing and monitoring
of operational areas that could potentially
raise compliance concerns. Some areas that
compliance officers should review on a con-
tinuous basis are: (1) effectively documenting
medical necessity; (2) Medicare/Medicaid bill-
ing practices; (3) repetitive patient transports;
and (4) facility contracted rates.
Additionally, ambulance providers that
are in the business of acquiring other “target”
providers should involve compliance in the due
diligence process. The compliance officer should
review the target organizations to ensure com-
pliance in all four of the above areas. This is
especially important with respect to Medicare
successor liability issues where the acquiring
organization could be left on the hook for the
past practices of the target. The first step to get-
ting involved in the due diligence process is to
communicate with the individuals responsible
for identifying and evaluating target organiza-
tions (e.g., CEO, CFO, general counsel, director
of mergers and acquisitions [MA]). In some
cases these individuals will be easily won over,
in which case the compliance officer will seek
to add compliance to the relevant document
requests and due diligence timeline.
However, most often these individu-
als will believe that they have sufficient due
diligence processes in place, and that any
compliance issues are currently mitigated by
the representation, warranties, and applicable
hold-backs. However, in my experience, these
individuals have only thought of the financial
impact of certain compliance issues (i.e., OIG
investigations), and have not accounted for the
associated administrative sanctions and penal-
ties. The administrative sanctions could include
Medicare payment suspension, pre-payment
review, or even exclusion of the acquired pro-
vider’s Medicare ID number and agreement.
These sanctions can obviously have financial
impacts that outpace the amounts in any hold-
back account, and may even end up being more
than the purchase price of the target.

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Once the compliance officer has won over
the organization’s MA stakeholders, he/she
must work to develop the process. The compli-
ance officer must assemble a team that will
have knowledge of the compliance issues
and the technical skills to review compli-
ance programs, patient care documentation,
and provider agreements. Once this team is
assembled, the compliance officer must create
a due-diligence document request that will
allow an evaluation of the full compliance risk
profile of the target. A good starting point for
such a document request is as follows:
1. Compliance policies and procedures,
the code of conduct, training records, the
name of the compliance officer, and evi-
dence of a hotline. Also include evidence
of systems to prevent false claims billing
and the methods used to report, refund,
and explain overpayments received from
the Medicare and Medicaid programs as
required by Section 6402 of the Patient
Protection and Affordable Care Act
(PPACA).
2. Ambulance transport records for 120
post-payment Medicare (primary payer)
non-emergency basic life-support patients,
including PCRs and Physician Certification
Statements (10 records from each of 12 one-
month date ranges).
3. A complete list of the scheduled non-emer-
gency repetitive transport patients (those
being transported three or more times in a
10-day period or at least once per week for
three consecutive weeks).
Once this information is collected from
the target entity, the compliance officer and
his/her team will review all the documenta-
tion against the relevant compliance standards
and requirements. The compliance officer will
then consolidate the review into a report that
can be easily understood by the organization’s
MA stakeholders.
6. Enforcing standards through
well-publicized disciplinary guidelines
A compliance program requires teeth to be
truly effective, and thus the provider must have
a well-publicized policy regarding violations
of the compliance policies and procedures and
code of conduct. Disciplinary actions regarding
compliance violations should be documented
thoroughly and usually include sanctions up
to and including termination. The individual
provider will have to look at its current HR poli-
cies to ensure compliance is a topic. Any and all
disciplinary actions should be implemented in
an equal and unbiased manner.
The compliance officer should be empow-
ered by the organization’s management to
develop compliance-specific metrics that will
be included in the employees’ performance
reviews (e.g., patient care documentation). The
chief executive-level officer must communicate
to the entire organization the importance of
compliance and that abiding by the compli-
ance policies and procedures is expected.
7. Responding promptly to detecting
offenses and taking appropriate
corrective actions
When a compliance violation is identified
through an audit, hotline report, or any other
method it must be investigated and prompt cor-
rective actions must be implemented. The failure
of organization to promptly identify and correct
compliance violations can lead to government
audits and investigations, qui tam actions, admin-
istrative sanctions, monetary penalties, and
damage to the provider’s reputation.
Corrective actions can take many forms,
but one that comes with additional require-
ments is a Medicare or Medicaid overpayment.
Once an overpayment is identified, the pro-
vider must work diligently to ensure that
the overpaid funds are returned to the gov-
ernment payer within 60 days. Any and all
corrective actions should be documented and

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kept on file to demonstrate the provider’s will-
ingness to correct violations on its own and
the effectiveness of the compliance program.
Compliance officers should develop and
implement the following:
·· A formal process for responding to
detected offenses. This process should
include the executive team to assist with
the assessment of the risk, prioritizing of
activities, and assignment of operational
responsibility and management of the
follow-up through resolution.
·· Formal enterprise-wide guidelines for
communicating with regulators and
external auditors to ensure consistency
across the organization. This should
encompass tracking and monitoring the
issue, establishing guidelines for the time-
frame for follow-up with business units to
ensure all issues were addressed and any
corrective actions were implemented and
tested to ensure effectiveness.
·· Formal system to organize, track, and
record the outcome of all communications
between the organization and regulators.
Governance and ownership
Accountability for the infrastructure, internal
processes, people, supporting technology, and
external events and changes is the backbone of
an organization’s effective compliance program.
Defining roles and responsibilities for processes,
people, and supporting technology related to
compliance activities at the board level and for
the executive leadership team is a first step in
ensuring the appropriate level of governance
and accountability of compliance across an
organization. Additionally, formalizing the
reporting for the compliance officer to the
board’s Audit Committee is of upmost impor-
tance to ensure the appropriate level of visibility,
transparency, and independence is present.
In addition, effective and transparent exchange
of operational information between business units,
the Compliance departments, senior management,
and ultimately, the board’s Audit Committee is a
core organizational competency to ensure they
work as a cohesive unit to encourage, identify,
assess, respond to, and correct (if necessary)
compliance-related performance and issues.
Conclusion
With the federal and state governments’ recent
emphasis on ambulance providers, it is imper-
ative that compliance programs are developed
and that these programs meet the govern-
ment’s expectations.
1. Centers for Medicare Medicare Services: Medicare Benefit Policy
Manual, Chapter 10. Available at http://go.cms.gov/14j4wQB
2. U.S. Government Accountability Office: “Cost and Medicare
Margins Varied Widely; Transports of Beneficiaries Have Increased.
GAO 13-6. October 1, 2012. Available at http://1.usa.gov/1EA9VOe
3. Office of Inspector General: “Medicare Payment for Ambulance
Transport.” January 2006. Available at http://1.usa.gov/1uqGeO9
4. Medicare Payment Advisory Commission: Report to Congress,
Chapter 7: Mandated report for ambulance services. June 2013.
Available at http://1.usa.gov/1GTtftQ
5. Corporate Integrity Agreement with First Call Ambulance Service,
LLC. May 29, 2014. Available at http://1.usa.gov/11lV8L3
2015 COMPLIANCE INSTITUTE
®
Preview
SESSION P7 The Wonderful NIST 800-30!
Guide for Conducting Risk Assessments
Sunday, April 19 9:00 am – 12:00 pm
Free stuff from the Feds! Did you know the National Institute of Standards and Technology (NIST) has dozens of free publications that can be
used in your compliance program? Come join us for a deep dive into the Guide for Conducting Risk Assessments. See how it can be used as
an assessment foundation for multiple risk areas and walk through real examples of conducting and documenting risk assessments.
To hear more, attend HCCA’s 19th
Annual Compliance Institute in Lake Buena Vista, FL!
Visit www.compliance-institute.org for more informatıon or to register.
Jim A. Donaldson
Director of Compliance/
Privacy Security Officer,
Baptist Health Care