Compliance

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Compliance

• Todd Phillips
• Thousand Cranes

2
INTERNAL MONITORING AND AUDITING

• GOAL
• In order to ensure the efficacy of Thousand
  Cranes Compliance efforts, and in order to
  determine whether Thousand Cranes is in
  compliance with applicable laws and regulations,
  we will engage in an ongoing effort to monitor
  and audit our billing and coding practices.
• POLICY AND PROCEDURE
• Thousand Cranes will monitor and audit its
  compliance efforts as follows
• Baseline audit Within sixty (60) days of
  adopting this compliance manual, Thousand Cranes
  will randomly select 25 previously submitted
  Medicare claims for review by an independent
  coding expert.
• Ongoing audits Every six (6) months following
  the baseline audit, Thousand Cranes will randomly
  select 10 previously submitted Medicare claims
  for review by an independent coding expert.
• Thousand Cranes will review all denied claims by
  Medicare in order to determine the reason for the
  denial.
• In reviewing the results from the
  above-referenced procedures, Thousand Cranes will
  make those changes necessary to ensure that
  proper coding and billing practices are adhered
  to and, if necessary, that changes are made in
  current billing and coding practices.

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SCREENING OF EMPLOYEES AND CONTRACTORS

• GOAL
• To hire and retain honest and ethical employees,
  in particular employees who have not been
  sanctioned by or excluded from any government
  health care program. In addition, to hire
  outside contractors and vendors who maintain high
  professional standards and who have not been
  barred from state or federal programs.
• POLICY AND PROCEDURE
• Thousand Cranes will screen prospective employees
  by
• Using the Employee Applicant Questionnaire
  (Appendix A)
• Asking appropriate questions in job interviews
  and/or
• Checking the OIG website for the list of excluded
  individuals (http//oig.hhs.gov/fraud/exclusions.h
  tml.)
• Thousand Cranes will screen prospective
  contractors and vendors by
• Checking the OIG website for excluded individuals
  (http//oig.hhs.gov/fraud/exclusions.html) and
• Checking the OIG website for barred contractors
  (http//epls.arnet.gov).

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EMPLOYEE TRAINING AND EDUCATION

• GOAL
• Thousand Cranes will ensure that its employees
  have sufficient training and education to
  understand and follow basic compliance principles
  and to competently and properly perform their
  duties.
• POLICY AND PROCEDURE
• Thousand Cranes will educate and train its
  employees by
• Providing all employees with a copy of this
  Medicare Compliance Manual
• Maintaining a compliance library with current
  coding reference materials and Medicare carrier
  bulletins accessible to all employees
• Sending Thousand Cranes employees to appropriate
  seminars and programs regarding Medicare
  compliance and billing and coding issues.
• Training and education through self-study of
  materials in Thousand Cranes compliance library,
  as well as communications received from the
  Medicare carrier, will be the primary means of
  employee education and training in Thousand
  Cranes. Employee training and education will be
  recorded by the Compliance Officer in the
  Training and Education Record

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NON-RETALIATION POLICY

• GOAL
• To encourage all employees, without fear of
  retribution or retaliation, to report instances
  of conduct that violate the policies and
  procedures in this Manual.
• POLICY AND PROCEDURE
• This Medicare Compliance Manual will be provided
  to all Thousand Cranes employees, along with this
  statement of policy that Thousand Cranes
  employees are to report any instances of
  perceived improper or inappropriate conduct with
  respect to coding and billing or other compliance
  matters contained herein.
• Compliance violations should be reported to the
  Compliance Officer.
• Thousand Cranes will not take any adverse
  employment action against employees who report
  potential Medicare compliance violations.

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RESPONSE TO COMPLIANCE VIOLATIONSAND
PREVENTATIVE MEASURES

• GOAL
• To ensure the integrity of the compliance plan,
  Thousand Cranes will respond to violations of the
  policies and procedures in this Manual. Further,
  Thousand Cranes will take the necessary steps to
  prevent similar violations from occurring in the
  future.
• POLICY AND PROCEDURE
• All reports of potential violations of the
  compliance plan will be investigated by the
  Compliance Officer. The Compliance Officer will
  record the results of the investigation on the
  Incident Report Form (Appendix C) and maintain
  this documentation.
• Based upon the investigation by the Compliance
  Officer, appropriate steps will be taken to
  ensure that the violation is not repeated. Such
  steps may include employee training, education
  and/or discipline. If necessary, this Manual
  will be amended to prevent further violations.
• To the extent that overpayments are discovered as
  a result of the Compliance Officers
  investigation, a refund will be promptly made to
  Medicare.

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CODING AND BILLING

• GOAL
• To ensure that Thousand Cranes follows
  appropriate coding and billing practices in
  compliance with Medicare rules, regulations and
  laws.
• POLICY AND PROCEDURE
• Thousand Cranes will keep and maintain updated
  coding and reference materials, including CPT,
  ICD-9 and HCPCS manuals.
• Thousand Cranes will retain and review all
  bulletins and information received from the
  Medicare carrier.
• Billing and coding personnel will follow
  appropriate coding rules as set forth in the
  compliance reference materials maintained by
  Thousand Cranes.
• Thousand Cranes will bill Medicare only for
  covered services however, if requested by the
  patient, or if necessary to obtain payment from a
  secondary payer, Thousand Cranes will submit the
  claim to Medicare with appropriate modifiers
  reflecting that the service is not covered and
  that the claim is submitted solely for the
  purpose of obtaining a denial.
• Thousand Cranes will bill Medicare only for
  services that have been documented in the records
  of Thousand Cranes.
• Thousand Cranes will bill Medicare only for
  medically necessary services however, if
  requested by the patient, or if necessary to
  obtain payment from a secondary payer, Thousand
  Cranes will submit the claim to Medicare with
  appropriate modifiers reflecting that the patient
  has signed an Advance Beneficiary Notice and that
  the claim is submitted for purposes of obtaining
  a determination by Medicare. ( Advance
  Beneficiary Notices)

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ENFORCEMENT OF COMPLIANCEPOLICIES AND PROCEDURES

• GOAL
• To ensure the strict enforcement of all
  provisions of this Manual. Further, to initiate
  appropriate disciplinary action for violation of
  the policies set forth in this Manual, as well as
  any violation of Medicare laws, rules or
  regulations.
• POLICY AND PROCEDURE
• The Compliance Officer will provide this Manual
  to all Practice personnel and will advise them
  that adherence to its provisions is a condition
  of employment.
• Practice personnel who violate the policies and
  procedures in this Manual will be subject to
  discipline, which may include termination of
  employment, as determined by the Compliance
  Officer after appropriate investigation

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CO-PAYMENTS AND DEDUCTIBLES

• GOAL
• To ensure that Thousand Cranes complies with
  Medicare rules and regulations regarding
  co-payments and deductibles.
• POLICY AND PROCEDURE
• Thousand Cranes will not routinely waive
  co-payments and deductibles of Medicare patients.
• Thousand Cranes will allow a waiver of
  co-payments or deductibles only where there is
  documentation of financial hardship from the
  patient.
• Absent documentation of financial hardship,
  Thousand Cranes will undertake reasonable
  collection efforts by sending reminder billings
  to patients and/or referring the matter to
  collection.
• Waivers of co-payments or deductibles will not in
  any circumstances be given to potential referral
  sources.
• Thousand Cranes will not advertise waiver of
  co-payments or deductibles or an insurance
  billing only.

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CREDIT BALANCES

• GOAL
• To establish proper procedures for handling
  credit balances on patient accounts.
• POLICY AND PROCEDURE
• Thousand Cranes shall issue refund request on
  credit balances to Medicare, the patient or
  third-party payers within a reasonable time.
  Absent justifiable circumstances, such refunds
  generally will be made by the end of the month or
  within thirty (30) days.

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ADVANCE BENEFICIARY NOTICES

• GOAL
• To ensure proper use of Advance Beneficiary
  Notices to properly notify patients and prevent
  liability to Thousand Cranes.
• POLICY AND PROCEDURE
• Thousand Cranes will request a Advance
  Beneficiary Notice (ABN) form in situations where
  Medicare may deny payment due to lack of medical
  necessity, but where the services would otherwise
  be covered by Medicare.
• The ABN forms must be signed by the patient prior
  to services being rendered.
• Thousand Cranes will use the CMS authorized ABN
  form, attached hereto as Appendix D to this
  manual.
• The ABN form will be filled out to specifically
  describe the service or procedure and the reason
  for Medicares potential denial of payment.
• Improper or indiscriminate use of ABN forms will
  be avoided by Thousand Cranes.

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BUSINESS RELATIONSHIPS

• GOAL
• To ensure that Thousand Craness business
  relationships and contracts do not violate state
  and federal laws.
• POLICY AND PROCEDURE
• Thousand Cranes will endeavor to ensure that all
  of its business relationships and contracts
  comply with state and federal laws by
• Having all contracts with other health care
  providers, vendors, or others, reviewed by health
  care counsel.
• Requiring that all contracts entered into by
  Thousand Cranes will be at fair market value and
  in writing.
• Prohibiting Thousand Cranes employees from
  receiving or giving inducements to referral
  sources.

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PROFESSIONAL COURTESY

• GOAL
• To ensure that professional courtesy arrangements
  do not violate fraud and abuse laws.
• POLICY AND PROCEDURE
• A Professional courtesy means providing services
  without charge (in whole or in part) to Practice
  employees, other physicians, and/or their
  families in relation to services provided by
  Thousand Cranes. Thousand Cranes may extend
  professional courtesy, as so defined, only if
  the following conditions are met
• The professional courtesy is provided in a manner
  that does not take into account the recipients
  ability to generate referrals for Thousand
  Cranes
• The total value of the services for which
  professional courtesy is extended may not exceed
  300.00 per person annually
• Thousand Cranes may not waive co-payments or
  deductibles only.

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FINANCIAL RECORDS

• GOAL
• To maintain and preserve accurate financial
  records.
• POLICY AND PROCEDURE
• Accurate business records will be maintained by
  Thousand Cranes at all times. All payments or
  receipts will be recorded in detail in Thousand
  Cranes business records. With the exception of
  disbursements from petty cash funds, Thousand
  Cranes will not make cash payments.

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RECORDS MANAGEMENT AND RETENTION

• GOAL
• To ensure proper maintenance and retention of the
  records of Thousand Cranes.
• POLICY AND PROCEDURE
• Thousand Cranes will create, maintain and retain
  those documents required by law and necessary to
  its operations. In particular, all records and
  documentation substantiating or supporting
  Medicare billing submissions will be retained by
  Thousand Cranes.
• The documents and records created by this
  Practice will be retained for the time required
  by law and in the manner required by law.
  Currently, it is Thousand Cranes policy to retain
  medical records 7 years.
• If and when it is determined that records will be
  destroyed, this will occur by shredding or in
  another manner necessary to obliterate
  confidential information, including patient name,
  Social Security number, Medicare number and any
  other potentially identifying information

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PRIVACY AND CONFIDENTIALITY

• GOAL
• To ensure compliance with state and federal
  privacy and confidentiality laws with respect to
  health information.
• POLICY AND PROCEDURE
• Thousand Cranes will follow all state and federal
  laws relating to patient privacy and
  confidentiality.
• Thousand Cranes will implement appropriate
  safeguards to prevent improper use or disclosure
  of patient health information.
• Thousand Cranes will not release or disclose
  patient health information without a signed
  authorization from the patient.