This document discusses the importance of compliance programs for ambulance services. It outlines key federal agencies and regulations related to compliance, including CMS, OIG, ACA, FCA and AKS. The OIG requires ambulance services to implement a seven-element compliance program. Non-compliance can result in fines and penalties. The document urges services to conduct internal audits, ensure documentation like PCRs support medical necessity and billing, and check that billing companies follow proper coding methods. Maintaining a strong compliance program is necessary to avoid issues with regulators and ensure ambulance services are paid appropriately.

1. COMPLIANCE
ANYONE DOING IT???
Dan Williams

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. 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?

6. COMPLIANCE
What Does Compliance Mean?
Meeting certain standards that are set out
by…
Individual Department
State Agencies
Federal Agencies

7. 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)

8. 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

9. 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

10. 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

11. 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

12. 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…

13. 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.

14. 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

15. 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/

16. COMPLIANCE
Internal Audits…
How many people are doing internal
billing audits?
If you do… How are they done?

17. COMPLIANCE

18. COMPLIANCE
DOCUMENTATION
PCR’S
WHAT DO YOURS
LOOK LIKE

19. COMPLIANCE
How to Determine if call is an EMERGENCY?
Dispatch information
9-1-1 call or equivalent
Immediate response documented

20. 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?

21. 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

22. COMPLIANCE
Over payments
What does that mean?
What do you have to do if you have been
overpaid?
60 DAY REPAYMENT RULE

23. 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?

24. 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?

25. NOW THAT WE ARE DONE
BLOWING OFF SOME STEAM…

26. WE HAVE HIT THE FINISH LINE

27. QUESTIONS??