SUBJECT: CORPORATE COMPLIANCE: BILLING & CODING COMPLIANCE MISSION: Quality, honesty and integrity, in everything we do, are important values to all of us who are associated with ENTITY NAME ( ENTITY NAME ). Methodist Hospital is committed to the proposition that all billings for patient services and other transactions must be properly documented and authorized by management. All records must be accurately and completely supported in Methodist Hospital s books and records. ENTITY NAME has implemented a Corporate Compliance Program to assist with healthcare billing and coding compliance. Healthcare billing and coding compliance refers to ENTITY NAME ability to operate within the laws, rules, regulations, and polices set by the federal and state governments, insurance programs and Medicare carriers, and fiscal intermediaries. PURPOSE: To ensure employees and business partners of the hospital comprehend and understand how to perform the duties and responsibilities while adhering to applicable federal and state laws and regulations. Sincere efforts made towards the prevention, detection and correction of any potential fraud, abuse or waste in the Hospital is a requirement for all employees, agents and contractors. The Corporate Compliance Program is a process for identifying and reducing risk and improving internal controls. ENTITY NAME is committed to full compliance with the Federal and State False Claim Act (FCA) and the Deficit Reduction Act of 2005 (DRA). This policy is intended to provide all employees, management, and contractors or agents of ENTITY NAME with detailed information regarding the FCA, Whistleblower protections, and ENTITY NAME Corporate Compliance Program policies and procedures for detecting and preventing fraud, waste and abuse. POLICY: The FCA was first enacted in the wake of Civil War profiteering which imposes civil liability on organizations and individuals that make false claims to the government for payment. The FCA authorizes federal prosecutors to file a civil action against any person or entity that knowingly files a false claim with a federal health care program, including Medicare or Medicaid programs. The FCA applies to providers, beneficiaries, and health plans doing business with the federal government, billing companies, contractors, and other persons or entities connected with the submission of claims to the government. The FCA is set forth in title 31 of United States Code, beginning with section 3729. The government can use the FCA against both organizations and individual employees who commit billing fraud. It applies to any person who does the following: (1) Knowingly presents or causes to be presented, a false or fraudulent claim for payment or approval to an officer or employee of the United States government; (2) Knowingly makes, uses or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the government; (3) Conspires to defraud the government by getting a false or fraudulent claim allowed or paid; or
(4) Knowingly makes uses or causes to be made or used, a false record or statement or to conceal, avoid, or decrease an obligation to pay or transmit property to the government. Anyone who violates the FCA is liable for civil penalty of not less than $5,500 and not more than $11,000 per claim, plus three times the amount of the damages the government sustains. The government may also exclude violators from participating in Medicare, Medicaid and other government programs. Intentional submission of a false claim ruse are subject to federal criminal enforcement and may also be liable to the United States government for the costs of civil action brought to recover any penalties or damages. The government relies heavily on the federal and state FCA to prosecute billing fraud. The FCA authorizes what is known as qui tam actions and awards to qui tam plaintiffs. The FCA s qui tam provisions permit private persons to: (1) sue, on behalf of the government, persons or entities who knowingly have presented the government with false or fraudulent claims; and (2) share in any proceeds ultimately recovered as a result of the suit. The FCA includes provisions to discourage employers from retaliating against employees for initiating qui tam law suits. Any employee who is terminated, demoted, suspended or in any way discriminated against because of acts in support of an action under the FCA has a right to sue the employer for reinstatement, back pay and other damages. In addition to the federal FCA, California has its own False Claims Act, set forth in Sections 12650 through 12655 of the California Government Code. The California False Claims Act is triggered by claims for payment submitted to the state and its agencies. The California False Claims Act is very similar to the FCA in terms of the types of acts that give rise to liability. Like the FCA, the California False Claims Act allows private parties to sue on behalf of the state as qui tam plaintiffs. The FCA includes a provision that reduces the penalties for providers who promptly self-disclose a suspected FCA violation. The Office Inspector General self-disclosure protocol allows providers to conduct their own investigations, take appropriate corrective measures, calculate damages and submit the findings that involve more serious problems than just simple errors to the agency. As we have discussed, the punishment for filing a False Claim can be severe. ENTITY NAME may achieve success with its healthcare billing compliance so long as all employees, agents and contractors perform their duties and responsibilities correctly and taking initiative to ensure a culture of compliance. Assurances of the following are ways all ENTITY NAME employees can help improve billing and coding compliance. We shall maintain honest and accurate records of all our activities. We are committed to both accurate billing and submission of claims only for services that are actually rendered and medically necessary. We shall not file a claim for services that were not rendered or were not rendered as described on the claim form.
We shall ensure that diagnoses are properly coded and that they are supported by medical necessity requirements. We shall not use diagnostic information provided by a physician from earlier dates of services, unless conforming to approved standing orders. We are committed to ensuring that bills submitted for payment are properly coded, documented and billed in accordance with all applicable laws, regulations, guidelines and policies. We shall research all credit balances and refund any money received that is not due to us in a timely manner. We shall promote and adhere to the goal of full and accurate compliance with all laws and regulations. We shall not submit any claims for payment or reimbursement of any kind that are false, fraudulent, inaccurate, incomplete or fictitious. We shall bill for services using only charge codes that accurately describe the services that were provided. If inaccuracies are discovered in bills that have already been sent, we shall take immediate steps to alert the payer and correct the bill in accordance with the payer s guidelines and requirements. We shall submit claims only for services and supplies ordered by a physician or other authorized person and provided to the patient. Insufficient documentation to support the services provided is perhaps the most common reason for Medicare to deny or delay reimbursement. Physicians, nurses, and other practitioners must complete medical records and other documentation to prove that they provided items or services. We shall take particular care to avoid improper or illegal billing and coding practices such as upcoding and unbundling. PROCEDURE: All employees, agents and contractors of ENTITY NAME are required to, and responsible, for reporting healthcare billing compliance concerns, including actual or potential violations of law, regulation, policy, procedure. Without help from employees, agents, and contractors, it may be difficult to learn of possible compliance problems and make necessary corrections through prevention, detection and resolution of instances that do not conform to healthcare billing compliance. ENTITY NAME Corporate Compliance Program confirms a culture of open lines of communication, problem resolution and a strict non-retaliation policy to protect employees agents, and contractors that report in good faith a potential compliance issue from any form of retaliation.
All ENTITY NAME employees should make sure they are familiar with ENTITY NAME Corporate Compliance Policies and Procedures. In the event a discovery of a potential compliance concern that might lead to a violation of ENTITY NAME Policies and Procedures or any federal or state law or regulation, the employee should do the following: (a) In accordance with Policy #132 Corporate Compliance Problem Reporting and Non- Retaliation the employee, agent or contractor should report the problem to their immediate supervisor if they see something that looks suspicious. Supervisors typically are attentive to problems and will follow up appropriately. This policy prohibits any retaliatory action against an employee for reporting concerns regarding potential violations of ENTITY NAME polices and procedures or any federal or state law or regulation (b) Be persistent, if the supervisor is unresponsive or if the employee feels they cannot inform their supervisor about the problem, the employee, agent or contractor shall raise the matter further up the chain of command and/or bring it to the Director of Corporate Compliance s attention. (c) The Director of Corporate Compliance will investigate all matters referred to determine what if any corrective actions are necessary. Issues and or concerns raised to the Corporate Compliance shall be investigated and resolved in accordance with Policy #### Corporate Compliance Issue Resolution Process. (d) It is recognized that detection and timely reporting of misconduct will help maintain the integrity of the organization and reserve its status as reliable, honest and trustworthy healthcare provider. Furthermore, penalties and sanctions can be materially reduced by voluntarily disclosures of violations of civil, criminal or administrative law in a timely manner. All disclosures shall be made in accordance with Policy #### Corporate Compliance voluntary Disclosure to Third Parties. (e) Consider an anonymous tip. Although ENTITY NAME does not allow any form of retaliation against employees who report instances of noncompliance, employees may feel more comfortable reporting the situation without revealing their identity. Therefore, in accordance with Policy #### Corporate Compliance Employee Hotline Operation, employees, agents and contractors may report concerns or problems anonymously or in confidence via the Hotline Services. Other Corporate Compliance policies and procedures that are intended to avoid any potential problems with fully complying with all applicable federal or state statutes or regulations related to billing for services are: (a) P&P #### Corporate Compliance Auditing and Monitoring and P&P #129 Auditing and Monitoring, Response, Follow-UP and Resolution provide details of periodic auditing of potential risk areas;
(b) P&P #### Corporate Compliance Education and Training via written policies and procedures and/or training to employees, agents and contractors, (c) P&P #### Corporate Compliance Enforcement and Discipline provides the Rendering of appropriate discipline for the failure of any ENTITY NAME personnel to comply with the ENTITY NAME policies and procedures or any federal or state laws or regulations. REFERENCE: Deficit Reduction Act 2005 31 U.S.C. Money and Finance Subchapter III Claims against the United States; 31 U.S.C. 3729. False Claims, 31 U.S.C. 3730 Civil Actions for False Claims, 31 U.S.C. 3731 False Claims Procedure, 31 U.S.C. 3732 False Claims Jurisdiction, and 31 U.S.C. 3733 Civil investigative demands. The California False Claims Act, Cal. Gov t Code 12650 12655 Article 9 False Claims Actions. Section 12653 Employer interference with employee disclosures, etc.; liability of employer, remedies of employee of the California False Claim Act. APPROVED: PRESIDENT EFFECTIVE: REVISED: REVIEWED: