Hospital Compliance Subcommittee Monitoring Plan 2016

Size: px

Start display at page:

Download "Hospital Compliance Subcommittee Monitoring Plan 2016"

Shanon Jackson
9 years ago
Views:

1 Payments for Patients Diagnosed with Kwashiorkor This audit will determine whether the diagnosis is adequately supported by documentation in the medical record. LVAD & TAVR Procedures We will review accounts to ensure that Medicare and FDA coverage criteria and billing requirements are met. Oversight of Hospital Privileging We will review Medical Staff credentialing and granting of initial privileges. Medicare Inpatient and Outpatient Hospital Claims for the Replacement of Medical Devices (device credits) This audit will assess our compliance with Medicare policy regarding the replacement of medical devices including device credits. E&M Services- New-Patient Rate and Inappropriate Payments We will review outpatient E&M services for clinic visits billed at the new-patient rate to determine whether they were appropriate. We will also ensure that the documentation supports the level of service billed. Serious Reportable Events (4th Qtr 2015) Restraint Deaths (4th Qtr 2015)

Oversight of Hospital Privileging We will review Medical Staff credentialing and granting of initial privileges.

2 End Stage Renal Disease Billing We will perform a comprehensive review of all aspects of ESRD billing. Medicare Secondary Payer This audit will assess our compliance with the Medicare Secondary Payer Policies. Payments for Transforaminal Epidural Injections This audit will assess Medicare claims to ensure that we are documenting and billing appropriately. Questionable Billing for Outpatient Mental Health Services by Medicaid Providers We will review payments for Medicaid outpatient mental health services to identify questionable billing patterns. Medicaid PT, OT, and Speech Therapy Services: Appropriateness of Payments This audit will assess the appropriateness of the hospital's billing for PT, OT, and Speech Therapy services. Bone Marrow or Stem Cell Transplants We will determine whether Medicare payments were paid in accordance with Federal rules and regulations. Transplantations are covered under Medicare only for specific diagnoses. We will ensure that these claims are being billed correctly. 2nd Important Message from Medicare Laboratory Tests-Billing Characteristics and Questionable Billing (top 25 clinical diagnostic lab tests)/reference Lab We will review Medicare stays to ensure that the 2nd Important Message from Medicare was received and documented appropriately. This audit will assess the hospital's billing of lab tests to verify that all billing requirements are met.

Payments for Transforaminal Epidural Injections This audit will assess Medicare claims to ensure that we are documenting and billing appropriately.

3 Serious Reportable Events (1st Qtr 2016) Restraint deaths (1st Qtr 2016) Risk Adjustment Data-Sufficiency of Documentation Supporting Diagnoses We will review medical record documentation to ensure that it supports the diagnoses that are submitted to CMS for risk-score calculations. Pancreas & Liver Transplants We will review transplant accounts to ensure that Medicare coverage criteria and billing requirements are met. Air Ambulance Level of Transport Requirements We will review claims to determine whether the appropriate level of transport was billed and determine that transports were medically necessary. Medicare Outpatient Payments for Chemotherapy Drugs We will review Medicare outpatient claims for our top 10 chemotherapy drugs to determine whether they were billed correctly. Payments for Mechanical Ventilation We will review Medicare claims for mechanical ventilation to verify that ventilation was coded correctly. Payments for Cancelled Surgical Procedures We will review inpatient hospital claims for cancelled surgical procedures to verify they were coded and billed appropriately. This will also include medication billing.

Pancreas & Liver Transplants We will review transplant accounts to ensure that Medicare coverage criteria and billing requirements are met.

4 Family ning Services We will review claims for family planning services to ensure they are coded correctly and meet Medicaid's guidelines. Dental Services for Children- Inappropriate Billing This audit will determine whether dental providers are billing dental services appropriately according to the EPSDT services benefit. New Inpatient Admission Criteria (2 MN Rule)/Observation Services We will review inpatient and outpatient observation claims to ensure we are admitting and billing appropriately. Selected Inpatient and Outpatient Billing Requirements We will review Medicare claims that may be at risk for overpayments. Serious Reportable Events (2nd Qtr 2016) Restraint deaths (2nd Qtr 2016) Living Donor Billing (kidney transplants) We will billing for kidney transplant cases to ensure billing was appropriate.

New Inpatient Admission Criteria (2 MN Rule)/Observation Services We will review inpatient and outpatient observation claims to ensure we are admitting and billing appropriately.

5 Oversight of Pharmaceutical Compounding We will review pharmaceutical compounding to ensure the safety of the procedures. 340B Program- Contract Pharmacy Arrangements and Part B Payments for Drugs Purchases under 340B Duplicate discounts We will review pharmacy practices to ensure we are in compliance with 340B Program requirements, including duplicate discounts. Brachytherapy Reimbursement/IMRT (intensity modulated radiation therapy) CRNA Billing This audit will assess our compliance with billing for Brachytherapy/IMRT. This audit will assess the billing of CRNA services by the hospital. Medicare/Medicaid Outpatient Dental Claims We will review claims for dental services to determine whether payments were made in accordance with Medicare requirements. Duplicate and Indirect Graduate Medical Education Payments With assistance from Hospital Financial Services, we will review the accuracy of resident information included on the cost report to ensure that there are no instances of a UMMC resident being counted inappropriately by another facility and also that our IME payments are calculated correctly. Review of Cardiac Catheterization and Heart Biopsies We will review claims for right heart catheterizations and heart biopsies billed during the same operative session to determine whether these procedures were coded and billed appropriately. Electrodiagnostic Testing (EMG's) We will review claims for EMG's and Nerve Conduction tests for medical necessity, correct coding, and billing.

requirements, including duplicate discounts.

6 Medicare Payments for the Drug Herceptin This audit will review claims for Herceptin to ensure that appropriate documentation is present and the accounts were billed accurately. Hospital Admissions with Conditions Coded either Present- on- Admission or Hospital Acquired (Medicaid) This audit will review the coding of Hospital Acquired Conditions and the use of Present on Admission Indicators to ensure Medicaid guidelines are being followed. Serious Reportable Events (3rd Qtr 2016) Restraint Deaths (3rd Qtr 2016) Utilization of Sleep Testing Procedures We will review claims for sleep testing procedures to determine whether they were performed & billed in accordance with Medicare requirements. Patient Choice This audit will be done to ensure that patients are provided adequate information to make informed decisions about post-hospital care. Medicare payments during MS-DRG payment window (72 Hour Rule) We will review claims to ensure that outpatient claims billed to Medicare Part B for services provided during inpatient stays were allowable and in accordance with IPPS billing guidelines.

Admission Indicators to ensure Medicaid guidelines are being followed.

7 Duplicate Payments for Beneficiaries with Multiple Medicaid Identification Numbers We will review Medicaid claims to identify any patients who may have more than one Medicaid ID number and for whom multiple Medicaid payments were made for the same period. Medicare Payments for Incarcerated Beneficiaries We will review claims for incarcerated beneficiaries to ensure that that they are being billed correctly. Payments for Services After Beneficiaries' Death/Including payments for HIV Drugs We will review claim dates to determine if claims have been submitted for service dates after a beneficiaries' date of death.

Medicare Payments for Incarcerated Beneficiaries We will review claims for incarcerated beneficiaries to ensure that that they are being billed correctly.

Medicare. Medicare Overview. Medicare Part D Prescription Plans. Medicare

Medicare. Medicare Overview. Medicare Part D Prescription Plans. Medicare 58 requires enrollment as soon as a retiree, spouse or dependent of a retiree is eligible for. Parts A & B MUST be elected. Overview There are three parts to : Hospital Insurance (also called Part A. Your