AMBULANCE SERVICE COMPLIANCE

Transcription

1 AMBULANCE SERVICE COMPLIANCE What s Your Responsibility? North Dakota EMS Association Management Conference June, 2016

2 The Rules: Who Sets the Rules Who Governs Healthcare? Federal Courts Congress Agencies Center for Medicare and Medicaid Services (CMS) Others

3 The Rules Who Sets the Rules Who Governs Healthcare? Regional Offices Subject Specific Agencies DEA DOT FDA FAA Homeland Security About 100 others.

4 Why Do We Need a Compliance Program? Patients Expectations Trust in your service Representatives of Communities Healthcare Partners Expectations All are required to have a Compliance Program Expectation of your compliance just as they comply Positive Reflection of Your Service Investigations Employees know the rules

5 Why Do We need a Compliance Program? Federal Government Required Federal Register March 24, 2003 Result of Fraud and Abuse Billing Practices by EMS Providers: Upcoding of Bills Non Medically Necessary bills False documentation calls billed which didn t occur Kickbacks payment for patients

6 Seven Elements of an Effective Compliance Program Development of Policies and Procedures Designation of a Compliance Officer Education for Staff Initial and Continuing Education Internal Monitoring Practices

7 Seven Elements of an Effective Compliance Program Appropriate Response to Alleged or Identified Situations Reporting Options for Employees Confidential reporting required No retaliation! Whistleblower protection Demonstration of Enforcement of Policies

8 1. Policies and Procedures Development of your Compliance Plan Include list of policies Code of Conduct Expectations of all employees Honesty, Integrity Respect of other employees Respect of patients Refrain from Conflict of Interest Clear, Short and Applicable

9 1. Policies and Procedures Billing Practices What is required on your PCR Signatures Medical Necessity Documentation of procedures Accurate Mileage General Odometer Readings vs. Actual Mileage Tenths of miles required Billing Service s Expectations

10 1. Policies and Procedures Run Review Practices Clinical reviews for education Billing reviews for compliance Who reviews? Policies for Expected Performance Vehicle checks Equipment usage Confidentiality Corrective Action Process Other policies

11 2. Education Initial Education New employee orientation Introduction to all policies and procedures Clearly defined performance expectations General education for all staff Specific education based on role within the service Operational staff Business office / administrative staff

12 2. Education Periodic Education Refresher of program Reintroduction of policies and expectations Review of areas of concern from previous education program Recommended post training exam or quiz Documentation Retention of rosters from ALL sessions Verification of education provided Retention of course outline verification of what was discussed

13 3. Review of Calls and Claims for Payment Expectations of the Ambulance Service Accurate information Medical Necessity If not medically necessary appropriate billing! Heightened alerts returns to Skilled Nursing Facilities or patient s home Dialysis

14 3. Review of Calls and Claims for Payment Policy to address frequency of reviews Pre billing vs. post billing reviews Identify errors and source Same individual Same general condition Remedial education for all or for one

15 4. What if We Identify a Problem? Billing Errors Undercharge Phase of billing Decision to rebill for undercharge or accept loss Overcharge Phase of billing Change in billing statement Repayment of overage

16 4. What if We Identify a Problem? Ambulance Service Responsibility Billing service accepts what is given Bills from PCR and other information supplied Billing service complies with rules for their role, not for ambulance services role

17 4. What if We Identify a Problem? Intentional Billing Differences Contract rates for less than what others are billed Friends of the service Healthcare facility patients vs. general public Structured Differences Permissible Rates for tax payers vs. those not from the area Clear and transparent policy / practice Subscription Services Care in how service is valued Membership (aggregate) dollars need to reflect costs to non members

18 4. What if We Identify a Problem? Is it Reportable? Self Reported Demonstrates Compliance Discovered by Someone Else? Viewed as no compliance Stiffer penalties Consult Billing Vendor or Legal

19 4. Other Compliance Responsibilities Employee Sanction Checks Medicare Exclusions Data Base Initial screening time of hire Requirements now for monthly checks Individual searches by name Records maintained for search results Free to use, can contract for services to perform this Positive results or like name positives Termination of employee Documentation of like name and validation this is not your employee

20 4. Other Compliance Responsibilities Prioritize Risks Service environment dictated Added measures of monitoring / reaction to issues High Risk Compliance Scenarios Non Emergent Responses Transports from Hospitals to SNFs, Private Residences Medical necessity a must What is upcoding Pre Scheduled Transports

21 4. What is a Kickback? Referrals to a Facility Service enticed to bring patients to one facility vs. another Dollars paid to service for these transports Other benefits provided to services for transports Pizza for patients! Lunches or food for ambulance crews Anything of any value which unfairly lures patients

22 4. What is a Kickback? Ambulance Restocking Medications Supplies Open arrangement vs. under the table If You Question Any Agreement Seek Legal Advice

23 5. What is a Safe Harbor? Generally Not Considered a Bad Thing Space allocations hospital to ambulance service Garage facilities Office facilities Use of conference or class rooms Equipment (example): Hospital-owned and used by the ambulance service Educational Patient care

24 5. What is a Safe Harbor? Provided Services (example): Legal Administrative Clerical Expectations of Discounts for These Services is a Bad Thing!

25 6. Confidential Reporting Employees Reporting Concerns Must be assured of confidentiality Anonymous Options External Services No retaliation!

26 6. Whistleblowers Protected under Compliance Rules Often Feel Unheard or Apathy of Compliant by Administration Brought up concern multiple times Not taken seriously Entitled to Up to 30% of Fine Verified / validated concern Fine to service

27 7. How Do We Demonstrate Compliance? Policies In place Supported by governing agency (hospital, county, city) Staff are trained, aware and familiar Our experience Remedial education Realistic No policies for unrealistic situations Applicable service risk assessment

28 7. How Do We Demonstrate Compliance? Billing Reviews for Compliance Determine pre or post billing Percentage of calls to review Random What to look for Medical necessity Appropriate charges Appropriate mileage Signatures! What is your process?

29 7. How Do We Demonstrate Compliance? Billing Reviews for Compliance Physician s Certification Statements Maintain with patient record Assure in place prior to authorizing billing Assure accuracy of document

30 7. How Do We Demonstrate Compliance? Records of Reviews Log of calls reviewed Log of issues identified positive and negative Our Results Pre and Post Compliance % of claims with problems Favorable to the patient or payor % Overcharge %

31 7. How Do We Demonstrate Compliance? Record of Education Initial new employee orientation Refresher annual? Remedial response to identified issues

32 7. How Do We Demonstrate Compliance? Log of Complaints / Concerns Confidential Proper follow up Closure with complainant

33 7. How Do We Demonstrate Compliance? Compliance with Contracts Service Area Coverage agreements Event coverage agreements No discounts Tax payer supported rates OK to be less Assure consistent billing Restocking Agreements Billing Service Agreements Hospital Agreements for staff RNs, RTs, etc.

34 Exit Interviews Why are People Leaving? Compliance Issues? Ask for specifics Assure confidentiality Assure your commitment to follow up Standard Format Same questions Questionnaire format? Demonstration of your Intent Problems identified after exit Investigators see as a positive

35 What If We Discover Issues? Rectify If You Can Repayment of overcharges Decision to rebill undercharges or not Policy Changes Use example of need and desired goal Educate staff Education Start! Document! Continue!

36 Talk to Your Staff Gauge Their Feelings as to Compliance of Your Service Are there questions? Clear guidance? Use Feedback to Direct Training Use specific examples discussed Involve them in developing Assure Open and Transparent Environment

37 Role Identification Identify a Compliance Officer Service Director pros and cons Assure Confidentiality Compliance Committee Membership Service leadership Service staff Governmental representative Others? Assure all are aware of confidentiality

38 Start the Process Policies Designed Enacted Roles Identified Staff know the process

39 Start the Process Confidential Correspondence Assure all know and believe this Demonstrate by your actions Commitment to Follow Up Discuss compliance with staff Regular reports to governing board or agency

40 Relax. Compliance is Never Done Always a moving target Rules continue to change Services are Responsible for Maintenance of Compliance Covered entity must maintain compliance Intentional or unintentional non compliance Ignorance is no defense!

41 However Office of Inspector General Feelings No compliance program? Intentional shunning of responsibilities May be viewed as intent to commit fraud Corporate Integrity Program Not just for the large providers! Compliance Program? Attempts by ambulance service to comply Documented efforts in areas

42 Resources Each Other No need to start from nothing Use best practices Share information Government Web Sites Office of the Inspector General Medicare and Medicaid Services

43 Resources State Association Unified voice for providers Legislation or Rule assistance American Ambulance Association Membership perks access to information External Consultants / Education Programs

44 Please Remember Compliance is Your Responsibility Billing Services use your information to submit claims Billing Services comply with Rules and Programs governing them Assure All Know Their Roles Service Leadership Employees Local Governing bodies City County Hospital Joint Powers Board

45 THANK YOU Questions?