2004 2004 FPMP Compliance FPMP Compliance

Plan TrainingPlan Training

Brigid M. Maloney, JDBrigid M. Maloney, JD

Compliance OfficerCompliance Officer

bmaloney@buffalo.edubmaloney@buffalo.edu

(716) 829-3176(716) 829-3176

2004 Compliance Plan2004 Compliance Plan

Reviewed and approved by the FPMP Reviewed and approved by the FPMP Governing Board, FPMP Compliance Governing Board, FPMP Compliance

Committee, Clinical Chairs, and Committee, Clinical Chairs, and Practice Plan Auditors.Practice Plan Auditors.

Elements of an Elements of an Effective Compliance PlanEffective Compliance Plan

Code of Conduct and written policies and Code of Conduct and written policies and proceduresprocedures

Compliance monitoring assigned to Compliance monitoring assigned to designated compliance officer or contactdesignated compliance officer or contact

Comprehensive training and educationComprehensive training and education Internal monitoring and auditingInternal monitoring and auditing Open lines of communication and updatesOpen lines of communication and updates Disciplinary standardsDisciplinary standards Investigation and response to detected Investigation and response to detected

violationsviolations

Program OrganizationProgram Organization

FPMP Governing BoardFPMP Governing Board FPMP Compliance CommitteeFPMP Compliance Committee Vice President for Health AffairsVice President for Health Affairs FPMP Compliance OfficerFPMP Compliance Officer Practice Plan Compliance Practice Plan Compliance

CoordinatorsCoordinators Practice Plan Chart AuditorsPractice Plan Chart Auditors

Code of ConductCode of Conduct Compliance with all laws, regulations, Compliance with all laws, regulations,

policies and procedurespolicies and procedures Relationship with other providersRelationship with other providers Claims with third party payorsClaims with third party payors Controlled substancesControlled substances Confidential informationConfidential information Conflict of InterestConflict of Interest Business information and relationshipsBusiness information and relationships ViolationsViolations

COMPLIANCE PLANCOMPLIANCE PLANPOLICIESPOLICIES

* * ** * *

1. Education & Training1. Education & Training

Mandatory Annual Training: 2 hours Mandatory Annual Training: 2 hours biannuallybiannually

-- educational sessions with your auditoreducational sessions with your auditor

-- classes or seminars offered through classes or seminars offered through FPMP FPMP Compliance OfficeCompliance Office

-- presentations made by outside presentations made by outside consultants or consultants or medical billing specialistsmedical billing specialists

-- off-site conferences and/or seminars off-site conferences and/or seminars covering healthcare compliance topicscovering healthcare compliance topics

Education & Training, Education & Training, cont’dcont’d

Mandatory New Hire Training:Mandatory New Hire Training:

All new clinical faculty must attend a 1-All new clinical faculty must attend a 1-hour hour

compliance orientation and training compliance orientation and training session with session with

the FPMP Compliance Officer or his/her the FPMP Compliance Officer or his/her

designee. New hire training sessions will designee. New hire training sessions will be be

offered twice each year.offered twice each year.

2. Documentation2. Documentation

Complete and accurate medical Complete and accurate medical record documentation is one of the record documentation is one of the

most important objectives of the most important objectives of the Compliance Plan, and a popular area Compliance Plan, and a popular area of investigation by the Office of the of investigation by the Office of the Inspector General and US Attorney.Inspector General and US Attorney.

Documentation, cont’d.Documentation, cont’d.

The medical record may be used to The medical record may be used to validate:validate:

Site of serviceSite of service Appropriateness of services providedAppropriateness of services provided Accuracy of the billingAccuracy of the billing Identity of the health care provider Identity of the health care provider

who furnished the serviceswho furnished the services

Documentation, cont’d.Documentation, cont’d.All medical records must be complete All medical records must be complete and legible, and include the following:and legible, and include the following:

CC and/or reason for CC and/or reason for encounterencounter

Relevant historyRelevant history Physical examination & Physical examination &

findings by physicianfindings by physician Prior diagnostic test Prior diagnostic test

resultsresults Assessment, clinical Assessment, clinical

impression, or diagnosisimpression, or diagnosis Plan of CarePlan of Care

Date and legible identity of Date and legible identity of the observerthe observer

A statement of the rationale A statement of the rationale for ordering diagnostic and for ordering diagnostic and other ancillary services, if other ancillary services, if not easily inferred.not easily inferred.

Risk factors, patient Risk factors, patient progress, response to progress, response to changes in treatment, and changes in treatment, and any revision to diagnosisany revision to diagnosis

Addendums: dated the day Addendums: dated the day the information is added to the information is added to the medical record (not the the medical record (not the date the service was date the service was provided).provided).

Documentation, cont’d.Documentation, cont’d.

Claims for professional fee Claims for professional fee reimbursement must:reimbursement must:

Contain proper codes for service Contain proper codes for service provided provided

Contain documentation that Contain documentation that supports the codessupports the codes

Be submitted in the name of the Be submitted in the name of the provider who performed the service.provider who performed the service.

Documentation, cont’d.Documentation, cont’d.

Practice plan responsibilities:Practice plan responsibilities:

Adopt FPMP Compliance PlanAdopt FPMP Compliance Plan Implement own documentation Implement own documentation

guidelinesguidelines Train and educate clinicians, coders, Train and educate clinicians, coders,

billers, administrative staff, and billers, administrative staff, and auditorsauditors

DocumentationDocumentationSome quotes from your peers concerning the E/M Some quotes from your peers concerning the E/M

Guidelines:Guidelines:

Stupid (x2) Stupid (x2) Compliance is impossible, "medically necessary" is impossible. Compliance is impossible, "medically necessary" is impossible. Will not improve care, will increase paperwork and will be used to Will not improve care, will increase paperwork and will be used to

intimidate physiciansintimidate physicians Unnecessary and burdensome Unnecessary and burdensome Abusive, intrusive, outrageous, impossible to adhere to Abusive, intrusive, outrageous, impossible to adhere to Cumbersome, unnecessary, pain in the neck Cumbersome, unnecessary, pain in the neck Words do lie and liars can write Words do lie and liars can write A process by which the federal government attempts to gain control A process by which the federal government attempts to gain control

over medicineover medicine Justifying the jobs of bureaucrats and head hunters. Justifying the jobs of bureaucrats and head hunters. Part of a systematic breakdown of the physician-patient relationship Part of a systematic breakdown of the physician-patient relationship Increases my paperwork documentation time by about 25%, and I can Increases my paperwork documentation time by about 25%, and I can

charge nothing [for it]!charge nothing [for it]! A vain attempt to painstakingly ascertain a physician's mental work A vain attempt to painstakingly ascertain a physician's mental work

product product

3. Self Referrals & 3. Self Referrals & KickbacksKickbacks

Anti-kickback StatuteAnti-kickback Statute

Stark LawStark Law

Anti-Kickback StatuteAnti-Kickback Statute

It is unlawful to offer, pay, solicit, or receive any It is unlawful to offer, pay, solicit, or receive any form of remuneration to induce or in return form of remuneration to induce or in return for:for:

Referring or arranging for any item or service Referring or arranging for any item or service payable under a federal health program; orpayable under a federal health program; or

Buying, leasing, or ordering, any good, facility, Buying, leasing, or ordering, any good, facility, service or item payable under a federal health service or item payable under a federal health care program. care program.

Remuneration is defined broadly to include the Remuneration is defined broadly to include the transfer of anything of value, in cash or in transfer of anything of value, in cash or in kind, directly or indirectly.kind, directly or indirectly.

Stark LawStark Law

Stark II prohibits a physician from making a referral to an

entity for the furnishing of designated health services

(“DHS”) covered by Medicare if the physician (or an

immediate family member of the physician) has a financial

relationship with that entity, unless a statutory exception

exists.

Stark LawStark Law“Designated Health Services”“Designated Health Services”

clinical laboratory services; physical therapy services; occupational therapy

services; radiology services; radiation therapy services; durable medical equipment

(DME) and supplies;

parenteral and enteral nutrients,equipment, and supplies;

prosthetics, orthotics, and prosthetic devices and supplies;

home health services; outpatient prescription

drugs; and inpatient and outpatient

hospital services.

Stark LawStark Law

Referral--Referral--A referral may be either a request for any DHS A referral may be either a request for any DHS

covered by covered by Medicare, including consultations and the tests or Medicare, including consultations and the tests or procedures performed by the consulting physician, procedures performed by the consulting physician,

or a or a plan of care by a physician that includes any plan of care by a physician that includes any

designated designated health service covered by Medicare.health service covered by Medicare.

Financial Relationship—Financial Relationship—May be various types of payments, compensation or May be various types of payments, compensation or

an ownership interest. an ownership interest.

4. Reporting Misconduct4. Reporting Misconduct

““All FPMP physicians and their All FPMP physicians and their employees are required to report employees are required to report any incidents of misconduct of which any incidents of misconduct of which the physician or employee is directly the physician or employee is directly aware or suspects.”aware or suspects.”

““Failure or refusal to report Failure or refusal to report misconduct or fraudulent or illegal misconduct or fraudulent or illegal practices may result in disciplinary practices may result in disciplinary action, including termination.”action, including termination.”

Examples of MisconductExamples of Misconduct Improper codingImproper coding Inadequate medical record Inadequate medical record

documentationdocumentation Falsification of medical recordsFalsification of medical records Acceptance of bribes or other kickbacksAcceptance of bribes or other kickbacks Unlawful attempt to induce referralsUnlawful attempt to induce referrals Unlawful self-referralsUnlawful self-referrals Retaliation against someone who has Retaliation against someone who has

reported a compliance violationreported a compliance violation

5. Internal Audit & 5. Internal Audit & MonitoringMonitoring

Practice plans are required to review the Practice plans are required to review the lesser of 2% of each physician’s submitted lesser of 2% of each physician’s submitted claims, or 20 claims per year.claims, or 20 claims per year.

Audit results are submitted to the FPMP Audit results are submitted to the FPMP Compliance Office.Compliance Office.

If physician’s charts are found to be less than If physician’s charts are found to be less than 70% compliant, then internal auditor must 70% compliant, then internal auditor must conduct an individual educational session conduct an individual educational session and perform a follow-up audit.and perform a follow-up audit.

Compliance rates of 50% or less on three Compliance rates of 50% or less on three consecutive audits will automatically trigger consecutive audits will automatically trigger an investigation by the Medical Compliance an investigation by the Medical Compliance Officer.Officer.

Auditing & MonitoringAuditing & MonitoringTop 10 coding errorsTop 10 coding errors

1. No documentation for services billed.1. No documentation for services billed.2. No signature or authentication of 2. No signature or authentication of documentation.documentation.3. Always assigning the same level of service.3. Always assigning the same level of service.4. Billing of consult vs. outpatient office visit.4. Billing of consult vs. outpatient office visit.5. Invalid codes billed due to old resources.5. Invalid codes billed due to old resources.6. Unbundling of procedure codes.6. Unbundling of procedure codes.7. Misinterpreted abbreviations.7. Misinterpreted abbreviations.8. No chief complaint listed for each visit.8. No chief complaint listed for each visit.9. Billing of service(s) included in global fee 9. Billing of service(s) included in global fee as a separate professional fee.as a separate professional fee.10. Inappropriate or no modifier used for 10. Inappropriate or no modifier used for accurate payment of claim. accurate payment of claim.

6. Internal 6. Internal InvestigationsInvestigations

What triggers an internal investigation?What triggers an internal investigation? Complaint to the Medical Compliance Complaint to the Medical Compliance

OfficeOffice Irregularities identified through auditsIrregularities identified through audits Threat of civil litigationThreat of civil litigation Potential government investigationPotential government investigation Receipt of a subpoenaReceipt of a subpoena

Goals of an Internal Goals of an Internal InvestigationInvestigation

Discover facts & circumstances Discover facts & circumstances surrounding alleged incidents of surrounding alleged incidents of noncompliancenoncompliance

Assess legal significance of facts Assess legal significance of facts discovereddiscovered

Evaluate legal rights and obligations of Evaluate legal rights and obligations of practice plan and physicianpractice plan and physician

Determine if there has been deliberate Determine if there has been deliberate wrongdoingwrongdoing

Stop the wrongdoingStop the wrongdoing

7. Corrective Action7. Corrective Action

Mandatory educationMandatory education Increased chart auditsIncreased chart audits Temporarily suspending billing Temporarily suspending billing Mandatory prospective audits of all Mandatory prospective audits of all

services before they are billedservices before they are billed Repayment or voluntary disclosure Repayment or voluntary disclosure

to appropriate payors or authoritiesto appropriate payors or authorities Termination from practice planTermination from practice plan

8. Appeals procedure8. Appeals procedure

Any practice plan member who Any practice plan member who disagrees with the corrective action disagrees with the corrective action taken or proposed against him/her taken or proposed against him/her by the Medical Compliance Officer by the Medical Compliance Officer may appeal the corrective action.may appeal the corrective action.

9. Governmental 9. Governmental InvestigationsInvestigations

Traditional areas targeted by Traditional areas targeted by governmentgovernment

Billing for services not renderedBilling for services not rendered Billing for services not medically Billing for services not medically

necessarynecessary Double billingDouble billing UpcodingUpcoding Unlawful kickbacks or referralsUnlawful kickbacks or referrals

What to do if an What to do if an Investigator arrivesInvestigator arrives

Obtain identification Obtain identification Ask to see documents authorizing the investigationAsk to see documents authorizing the investigation Request purpose of investigator’s visitRequest purpose of investigator’s visit Notify practice plan president or other individuals Notify practice plan president or other individuals

designated as contactsdesignated as contacts Assure full cooperation with investigatorsAssure full cooperation with investigators Remove all non-essential personnel from areaRemove all non-essential personnel from area Suspend routine destruction of records Suspend routine destruction of records Maintain log of all events associated with Maintain log of all events associated with

investigationinvestigation Remember: staff may ask to be interviewed at a Remember: staff may ask to be interviewed at a

later datelater date

10. Updates/Revisions10. Updates/Revisions

Minor revisions will be approved by Minor revisions will be approved by the FPMP Compliance Committeethe FPMP Compliance Committee

Major revisions must be approved by Major revisions must be approved by the Governing Boardthe Governing Board

Other FPMP Compliance Other FPMP Compliance ResourcesResources

FPMP Quarterly NewsletterFPMP Quarterly Newsletter Compliance Committee meeting Compliance Committee meeting

minutesminutes Auditing FAQ’sAuditing FAQ’s Practice Plan Training GuidePractice Plan Training Guide Individual Practice Plan Policies & Individual Practice Plan Policies &

ProceduresProcedures

A Sound Compliance A Sound Compliance ProgramProgram

FPMPCompliance

Plan

FPMP Governing

Board

PP Auditor

PPComplianceCoordinator

FPMPComplianceCommittee

FPMPCompliance

Officer

PracticePlan

Newsletter

Auditors meetings

Educational sessions

Practice plan oversight

Compliance plan review

Training sessions

Audit results reviewInvestigations

Periodic audits

Written standards

Code of Conduct

Reports violations

Reports violations

Policy revisions

Training Guide

ComplianceOversight

Corrective action

Brigid M. Maloney, J.D.Brigid M. Maloney, J.D.Compliance OfficerCompliance Officer

3435 Main Street, BEB Rm. 1493435 Main Street, BEB Rm. 149

Buffalo, New York 14214Buffalo, New York 14214

(716) 829-3176(716) 829-3176

bmaloney@buffalo.edubmaloney@buffalo.edu