25 Jan Many compliance problems occur in the process by which a hospital prepares and submits claims to payors for reimbursement of th
Many compliance problems occur in the process by which a hospital prepares and submits claims to payors for reimbursement of the services it has provided to Medicare and Medicaid beneficiaries. Which of the following procedures do you think would be most effective in preventing problems. In a few sentences, explain why you think so.
- A mechanism for maintaining effective, accurate communication channels between claims/billing staff and clinical staff.
- Medical records used as the basis for submitted claims are organized and legible to facilitate their audit and review.
- The compensation given to the claims department, coding clerks, and claims consultants does not function in any way as an incentive to improperly code claims.
-(use the PDF that I attached on the bottom – it will help)
-there is no word limit
Chapter 15
Learning Objectives
Elements of a hospital compliance program
High risk areas of hospital operations
Hospital-wide Standards of Conduct
Duties of the hospital Compliance Officer
Conducting compliance training and education
Open lines of communication
Continuously monitor program operations
Responses to possible compliance offenses
Example of a hospital compliance plan
Introduction
The purpose of a compliance program is to promote adherence to Federal and State laws on fraud abuse, and the program requirements of public & private health plans.
The Office of the Inspector General (OIG) in the federal Department of Health and Human Services (DHHS) has issued two guidances on the structure and focus of hospital compliance programs.
Compliance Risks Unique to Hospitals (I)
Outpatient services rendered in connection with an inpatient stay
Submission of claims for laboratory services
Physicians at teaching hospitals
Cost reports
Recruitment of physicians to medical staff
Attracting patient referrals to the hospital
Admission and discharge policies
Compliance Risks Unique to Hospitals (II)
Supplemental payments
Tax-exempt standards for non-profit hospitals
Gain-sharing arrangements between a hospital and its physicians
Antitrust implications of hospital decisions to merge with or acquire each other
HIPAA Privacy and Security Rules
Compliance Risks Unique to Hospitals (III)
Legal implications of trend for hospitals to purchase physician practices, align strategic hospital goals with those of physician practices, and enter into hospital-physician collaborations in support of an accountable care organization (ACO)
Compliance with EMTALA in the operation of hospital Emergency Departments
Benefits of a Hospital Compliance Program (I)
Identify & prevent criminal & unethical behavior
Ensure false & inaccurate claims not submitted
Facilitate employee reports of possible problems
Facilitate investigations of alleged misconduct
Initiate prompt & appropriate corrective action
Reduce exposure to civil and criminal penalties
7
Benefits of a Hospital Compliance Program (II)
Central source for information on fraud & abuse
Accurate view of employee misconduct
Identify weaknesses in systems and controls
Improve quality & efficiency of care delivery
Build hospital reputation for lawful & ethical behavior
Elements of an OIG Recommended Hospital Compliance Program
Standards of conduct, policies, and procedures
Designation of compliance officer and committee
Regular education and training programs
Process to receive complains
System to respond to complaints and enforce disciplinary action
Audit and monitor compliance
Investigation and correction of problems
Written Policies and Procedures (I)
The framework of the compliance program consists of written policies and procedures that identify the most critical risk areas in the hospital and prescribe how people should act in those areas.
Standards of Conduct
Claims preparation and submission process
Medical Necessity
Anti-Kickback and Self Referral Liability
Written Policies and Procedures (II)
Bad Debts
Credit Balances
Record Retention
Performance Management
Compliance Officer (CO) and Compliance Committee (CC)
CO is focal point for compliance activities throughout the organization
Full-time, access to CEO and BOD, sufficient staff and resources, adequate authority
Typical responsibilities
CC supports the CO in implementing the compliance program
Typical duties
Compliance Training and Education
Training in legal requirements and compliance program that addresses them.
Directed to hospital’s managers, employees, & physicians.
Hours per year, condition of employment, documentation of training activities.
Topics covered by the training.
Standards for evaluating effectiveness.
Open Lines of Communication
Reporting suspected incidents of non-compliance
Several independent reporting channels
Protect confidentiality and prevent retaliation
Criteria for evaluating the communications environment
Auditing and Monitoring
To identify non-compliance problems & maintain functionality/effectiveness of the compliance program
Periodic audits by internal or external auditors
Risk areas targeted by the audits
Initial baseline audit followed by regular measures of variations from that standard
Annual review of program activities
Responding to Detected Offenses with Corrective Action
Types of corrective action that may be called for when a violation is discovered
Value of reporting violations to government agency
Prevent destruction of evidence and documents
Factors in assessing how well a hospital deals with detected offenses
Disciplinary Action for Compliance Violations
Disciplinary action for violation of laws and compliance policies & procedures
Range of possible disciplinary actions
Rigorously screen job candidates to avoid hiring potential violators – looking for recent convictions, debarments, and exclusions
Review of Real-World Hospital Compliance Plans
MD Anderson Cancer Center example in book
Other examples on the internet
Other examples from local hospitals
How each example compares to the recommended practices described in this chapter
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