UIC College of Medicine Compliance Plan/Program

Transcription

1 UIC College of Medicine Compliance Plan/Program Updated for Calendar Year 2010 Policy: Each designated operating unit within the University of Illinois Medical Center at Chicago and its associated clinical departments under the College of Medicine s Faculty Practice Plan has adopted policies, procedures and/ or programs that meet and ensure compliance with applicable federal, state, or other regulatory requirements and regulations. Purpose: To provide a framework for adherence to all pertinent regulations, and a mechanism for preventing and/or reporting a breach in compliance. Procedure: The College of Medicine (COM) has developed a Compliance Plan/Program and distributed it to appropriate stakeholders. It is reviewed yearly and updated as necessary. This Plan/Program: 1. Designates a compliance officer to oversee compliance activities with established policies and procedures. Implementation and oversight of the COM compliance program is delegated to the COM Director of Compliance. The COM Director of Compliance collaborates with the University of Illinois Medical Center Director of Compliance and the Medical Center s Chief Compliance Officer The College of Medicine Director of Compliance: Oversees and monitors the College of Medicine Compliance Program. Assists in the revision of the Compliance Plan to conform to changes in the needs of the organization and laws and policies of government and private payers. Oversees auditing and monitoring activities whose responsibility is shared by the COM and clinical departments. Acts as a primary contact on matters relating to compliance. 1

2 Develops and oversees compliance education and training for the College of Medicine. Provides regular updates on compliance to impacted stakeholders, which may include the MSP Director, MSP Executive Committee, MSP Board of Directors, the Dean of the College of Medicine, and the Departmental Compliance Liaisons and business managers of the College of Medicine and Medical Center clinical departments. Disseminates information on compliance to clinical departments as appropriate. Represents the College of Medicine on Medical Center compliance committees. The heads of the clinical departments of the College of Medicine are ultimately responsible for the compliance within their respective departments. The clinical departments of the College of Medicine are as follows: Anesthesiology Dermatology Emergency Medicine Family Medicine Medicine Neurology & Rehabilitation Neurosurgery Obstetrics & Gynecology Ophthalmology Orthopedics Otolaryngology Pathology Pediatrics Psychiatry Radiology Surgery Surgical Oncology Urology Each department head shall designate a Departmental Compliance Liaison (DCL) to handle implementation and oversight of compliance within their department with the guidance and oversight from the COM Director of Compliance. The DCL: Assists the Department head in the development and implementation of compliance policies that pertain to the laws, regulations, and common practices within their department and clinical specialty as necessary. 2

3 Assists in any auditing and monitoring functions specifically developed by the department as well as those co-managed by the College of Medicine Director of Compliance. Submits reports on a quarterly basis to the College of Medicine Director of Compliance based on findings of auditing and monitoring activities. Acts as a primary contact to faculty and staff within the department on matters relating to compliance. Assists with and implements departmental aspects of the compliance education and training program, and develops and coordinates the education and training programs specific to the department. 2. Provides for ongoing review of ALL pertinent compliance regulations and policies to maintain acceptable standards of compliance. The COM Director of Compliance is responsible for staying current with ongoing regulations and policies pertaining to federal, state and local compliance regulations by using the following sources of information: Regular communications from, and meetings planned by, healthcare and compliance-related organizations. Such organizations include the Health Care Compliance Association and the Medical Group Management Association. Regular review of communications from the Centers for Medicare and Medicaid Services and its third party intermediaries. Risk Assessment On an annual basis, or more often as needed, the Director of Compliance, in conjunction with the College of Medicine s18 clinical departments perform compliance risk assessments to identify risk areas as a result of federal or state laws, regulations or investigative activities, or deficiencies in documentation, billing, or patient care. The primary sources of information for the annual risk assessment are the US Department of Health and Human Services Office of Inspector General Annual Work Plan, as well as the results of internal audits conducted by the Office of University Audits, the Medical Center Director of Compliance, and coding and documentation audits conducted by the Compliance Auditors under the direction of the College of Medicine s Director of Compliance. The results of the risk assessment shall be reviewed with the Director of the MSP and the Dean of the College of Medicine. Areas that are identified as a high risk shall be monitored on a quarterly basis, until such time as the COM Director of Compliance notifies the Medical Center Compliance Officer, or his/her designee, that monitors demonstrate the College of Medicine s success in managing and/or significantly reducing the risk. Information updates are collated electronically and communicated to Departmental Compliance Liaisons on a regular and ongoing basis. Any issues 3

4 deemed to increase compliance risk to the operating unit are promptly brought to the attention of the Department Heads and the COM Director of Compliance. 3. Establishes compliance policies and procedures to be followed by all employees within the operating unit. Members of the College of Medicine Medical Service Plan [defined as all providers in the College of Medicine who bill for clinical professional services through the Medical Service Plan], shall be expected to observe all applicable clinical, documentation and/or medical staff policies established of the University of Illinois Medical Center at Chicago (See the University of Illinois Medical Center Corporate Compliance Plan), or of the healthcare organization where the MSP provider is performing the service. Providers must also observe and comply with clinical and documentation requirements established by Medicare, Medicaid or other applicable third party insurance plans covering the patient for who care is being provided. Compliance policies and procedures for the College of Medicine (COM) are developed by the COM Director of Compliance with the approval of the Director of MSP. Proposed policies and procedures that are anticipated to have an impact on the clinical departments of the COM are vetted with the MSP Executive Committee, and transmitted to the UIC Medical Center Director of Compliance. Policies and procedures that impact the clinical departments of the COM are communicated to Departmental Compliance Liaisons at the time of development. Departmental Compliance Liaisons are responsible for disseminating information on compliance policies to faculty and staff within their department, and are also responsible for communicating to the COM Director of Compliance any new policies or procedures impacting compliance within their department. Maintains a compliance training program for all employees in the operating unit. Compliance training shall be required for employees in the following groups: Members of the Medical Service Plan [defined as all providers in the College of Medicine who bill for clinical professional services through the Medical Service Plan] Staff in the College of Medicine who involved in any aspect of professional clinical billing and/or coding. The content of compliance training, which shall be on a 2-year cycle, is based on the annual risk assessments. Individual clinical departments within the College of Medicine may choose, at their discretion, to institute additional compliance training requirements to address specific risk areas or training needs. 4

5 Participation in the COM Compliance Education & Training Program shall be documented electronically and shall be available to the Medical Center Compliance Officer upon request. 4. Establishes a monitoring and auditing program to detect non-compliant conduct by employees and other agents. Presence of Outpatient Attending Physician Documentation The COM Director of Compliance, on a quarterly basis, shall report on completion of appropriate documentation for encounters billed in the previous quarter. This report is generated by the DCL in each Clinical Department and shall utilize data from the University Audits DREAMS database, which searches billing records from billing services used by the College of Medicine and data from the electronic medical record of the University of Illinois Medical Center at Chicago. The results are reported to the Medical Center Compliance Officer as well as the head of each clinical department. Departments that fail to meet the required thresholds for presence of attending physician documentation shall be required to conduct remedial education. Follow-up auditing of individual providers is required for those who fail to include the required attending documentation in 95% of billed encounters Monitoring of Evaluation and Management coding trends in selected departments The COM Director of Compliance reviews the coding patterns of claims submitted by COM (MSP) physicians for outpatient Evaluation and Management services billed. On a yearly basis, all outpatient on campus clinics are audited per a schedule, to determine whether the level of service billed is supported by documentation in the medical record. The review shall identify the departments with the greatest degree in variance in E&M coding when compared to services billed by similar groups, as reported by the Faculty Practice Solutions Center of the University Health Care Consortium. Encounters reviewed shall be selected that can reasonably be considered representative of E&M services rendered by the academic department and division or section being reviewed. If the review indicates that the level of E&M codes selected cannot be generally supported by the documentation in the patient s medical record, the Director of Compliance shall work with the department to develop an action plan to address the risks and errors identified during the E&M coding monitoring process. This action plan may include a more thorough review of E&M codes, education or training tailored to the needs of the COM member and/or his/her division, section or department, or a prospective review process whereby claims undergo an additional review prior to their submission to a third party for reimbursement. Action plans must be developed and implemented within a time frame that is reasonable considering the level of risk or seriousness of errors identified. 5

6 Physician Coding and Documentation Audit In cooperation with the clinical departments, there is a retrospective review of samples of bills submitted to federal and state payers and the corresponding patient medical record documentation for every physician billing through the MSP. This review determines whether the sample of bills submitted were coded and documented in compliance with standards set for by Medicaid, Medicare, or its fiscal intermediaries. The results of the monitoring process are reported to Department Heads and Departmental Compliance Liaisons for further review and action. The billing and documentation review must meet the following requirements: The review shall be conducted on an ongoing basis and all MSP members are reviewed at least once each fiscal year. The review shall include at least five Evaluation and Management services and five non-e&m procedures billed to Medicare, Medicaid on behalf of each member of the Medical Service Plan within the review period. If less than five services of either type were submitted for reimbursement on the provider s behalf during the review period, all billed services of that type shall be reviewed. Claims that are representative of the procedures and services typically offered by the department or division/section are selected. Claims selected for review must be relevant to the specific risk areas identified by the individual department or section. Claims must be reviewed against the following criteria: 1. Appropriate use of CPT-4 code(s) as compared to procedure(s) described in documentation 2. Appropriate use of ICD-9 code(s) as compared to diagnosis/diagnoses described in documentation, and demonstration of medical necessity in medical record 3. Appropriate use of modifiers, and compliance with National Correct Coding Initiative guidelines 4. Appropriate use of GC (Teaching Physician) and GE (Primary Care Exception) modifiers 5. Presence of Attending physician verification/attestation medical record The results of the coding and documentation review are submitted to the Director of Compliance and sent to the appropriate Departmental Compliance Liaisons. If serious errors are identified during the review process, a larger sample of the provider s charges shall be reviewed. At this stage, departments are required to work in cooperation with the Director of Compliance to develop an action plan to address the risks and errors identified during the review process. This action plan may include an education or training program tailored to the needs of the COM member and/or his/her division, section or department, or a prospective 6

7 review process whereby claims undergo an additional review based on the criteria listed above prior to their submission to a third party for reimbursement. Action plans must be developed and implemented within a time frame that is reasonable considering the level of risk or seriousness of errors identified. 5. Provides for a mechanism to accept and investigate reports of possible or actual violations of the Compliance Plan within the operating unit. If the auditing and monitoring processes described above reveal violations of the compliance plan or policies, these are reported to the COM Director of Compliance, who determines the appropriate response. Alleged violations determined to represent significant risk to the Medical Center are promptly reported to the Medical Center Compliance Officer for internal investigation. Alleged violations will generally be brought to the attention of the Compliance Liaison by the Hot Line Process or other internal sources. All allegations are promptly brought to the attention of the COM Director of Compliance. An appropriate course of action is determined including direction by University Counsel as appropriate. When any action of a compliance nature is taken, a report is made to the Medical Center Compliance Officer and University Counsel. Departmental Compliance Liaisons are required to promptly notify the COM Director of Compliance of all alleged compliance violations. Compliance-related materials are maintained within the operating unit or forwarded to the Compliance Office as required. The Medical Center has policies (#LD 4.09 and #2.04) for the storage and/or destruction of such materials as well as Record Retention Policy with which all units are expected to comply. 6. Institutes appropriate disciplinary action if it is determined that any employee or agent has violated the policies and procedures adopted under the Compliance Plan or engages in non-compliant activities. The University of Illinois Medical Center at Chicago and the University of Illinois at Chicago have written policies setting forth the degrees of disciplinary actions that may be imposed on officers, managers, employees, health care providers and others for failure to comply with the University s and Medical Centers policies. Employees found to engage in intentional or reckless non-compliance behavior are subject to significant sanctions. All managers and supervisors are aware that they have a responsibility to discipline employees and other staff, in an appropriate and consistent manner for compliance infractions. They are also aware that they will be held accountable for foreseeable failure of their subordinates to observe policies and procedures. 7

8 The promotion of and adherence to the Compliance Program is an integral part of their annual Performance Evaluations. Violations of the Compliance Plan are reported as required by law. The COM Director of Compliance Officer or his/her designee makes such reports after consultation with the University's legal counsel. AUTHORIZED DATE TITLE REVIEWED: Bonnie G. Boerger RN, MSN, CHC, CPC DATE: April 2,