Chief Officer: by 2JFP7wu


									Chief Officer:

Compliance Committee:


By order of the Office of the Inspector General (OIG), this compliance program has been
written by the chief officer and the compliance committee. Each individual who is employed by
The Family Doctors of Belleview has reviewed and received a copy of our compliance program.
A signed acknowledgement to this effect is contained in the employees personnel file attesting
that the employees of ____________________________have read and understand these policies.
                             Practice Name
                         Goals of Compliance

1.   To conduct business in an ethical and lawful manner
2.   To educate all employees and physicians regarding federal programs
3.   To clearly communicate federal regulations to patients and their responsibility
     to uphold them
4.   To help educate our physicians and physician assistants on correct ethical
5.   To evaluate all billing and coding practices annually at a minimum
6.   To establish effective communication with employees and our physicians
     regarding compliance.
7.   To help our physicians and physician assistants improve medical record
8.   To maintain an excellent working relationship with Medicare and other payers
     of service
                                   Practice Name
                                 Code of Conduct

1. _____________________ will not charge for services not rendered.
2. Documentation of services rendered will be complete and legible.
3. Evaluation and Management coding will adhere to established Medicare
4. Diagnosis codes that are reported will be descriptive of the purpose for which a
   service was performed.
5. Modifiers will be used only when justified by the need for this service.
6. Medical necessity requirement will at all times be adhered too.
7. The Family Doctors of Belleview will validate all coding information by using
   reputable resources.
8. Medicare and CPT guidelines will be reviewed on an on-going basis.
9. ____________________________ will incorporate a commitment to compliance in
   all aspects of its business, including its personnel manual, criteria for hiring,
   evaluation tools and job descriptions.
                                    Practice Name
                        Billing Policies and Procedures

The following is a list of our procedures that are followed on a daily basis by all
billing employees/or front desk personnel of ___________________________:

1. All daily work sheets are checked for accuracy against the appointment schedule
   to make sure that we have a charge and payment if appropriate for each patient
   who was scheduled. The front desk office personnel notify all patients who did
   not keep their appointments in follow-up.
2. Provider charges are verified in our system for accuracy as far as procedure and
   diagnosis code and correct modifier use. Report is generated and matched against
   daily work sheet for accuracy.
3. Electronic claim submission to payers is done at the end of each day for those
   charges that were inputted that day. Reports are run to cross check that all claims
   are sent. Acceptance reports (EDI) are automatically generated by our third party
   payers and downloaded and printed the next morning. All front-end verification
   reports are kept on file.
4. All primary (1500) HCFA forms are run and matched to any appropriate
   documentation and mailed at the end of each day following the same format as we
   do for electronic claims submission.
5. Any payments (EOB’s) that are received on a daily basis are batched, each check
   is copied and inputted and balanced against the deposit for that day.
6. All secondary bills are also generated on a daily basis; during payment posting,
   appropriate patient statements are also generated at this time.

7. Claims requiring a formal appeal are brought to the attention of the manager, who
   reviews and determines if the appeal process should take place. If appeal is
   processed, it is sent with all appropriate documentation (copy of coding manuals,
   inpatient/outpatient progress notes, discharge summaries or consultation reports
   etc.) is attached to the appropriate appeals form. Forms are mailed, copies are
   kept, and patient account is noted by placing a note on the account for follow-up
   in 30 days. If appeal is denied, manager is notified and makes the final decision
   on final disposition of account.
8. All routine claims follow up begins at day 31, carriers are called and if necessary,
   resubmission and or correction of claims occur. All follow-ups are properly
   documented in account notes within the patient’s individual account.
9. Any overpayment that occurs during payment posting creates a negative balance
   in the patients account. Manager is notified via refund request form to secure
   refund to either patient or insurance company. No insurance account is left in
   negative status longer than 60 days.
10. All patients who are balance billed are notified of their balances by generating
   three (3) patient statements. The third statement notifies the patient of our
   practices intent to turn their account over to our collection agency for recovery.
11. All effort is made to collect any account over 45 days; all patients are offered
   options to settle their account, either by making payment arrangements, credit
   card or credit card consent on file or by post dated check.
                                   Practice Name
                                 Coding Policies

1. All Inpatient billing is reviewed and coded as appropriate from the physician
   billing form, progress notes, hospital consultation forms pathology and discharge
   summary information. Any questions regarding the procedure codes are directed
   to the appropriate physician who billed the service. Physicians are exclusively
   responsible for choosing the level of care through the use of CPT codes. If
   necessary the use of a modifier is applied to let the carrier know that an additional
   payment is requested, or to offer a better description of the procedure.
2. Any coding problems or questions are brought to the attention of the manager for
   accurate coding, if the manager needs any additional clarification, the manager
   will bring the problem to the attention of the physician who performed the
   procedure/service or chose the evaluation and management code (E&M).
3. Any procedure or service that is not clearly documented will not be coded and
   billed without clarification from the attending physician.
                                   Practice Name
                                  Risk Assessment

1. Billing for items or services not actually documented, if on occasion a physician
   neglects to mark a service or item provided during a office or inpatient
   visit/procedure, the billing staff will contact the manager and will check the
   patients progress note, chart consult sheet or dictated documentation to clarify
   whether the service was billed appropriately, if after reading the patients progress
   note, chart consult sheet or dictated documentation the billing staff and manager
   are unclear as to whether the service was performed, they will contact he
   physician in question who reported the service.
2. Unbundling of services is not permitted; ___________________________
   continually updates the correct coding initiative material to prevent unbundling.
3. Up coding is not permitted by billing staff, all office procedures and or visits are
   chosen by the appropriate physician providing the service.
4. Inappropriate balance billing is not permitted by the billing staff, all insurance
   companies and patients balances are billed according to specific carrier
5. The use of passwords and appropriate levels of security within our
   ___________________ software system maintain computer program security at
6. Confidentiality is maintained on all patient health and billing information. Each
   employee of ___________________________________ when hired sign and
   agree to up hold all patient information in strict confidence. Employees are
   informed that patient account information is not discussed with anyone but the
   An individual must give their birth date and social security number before any
   information is discussed. If the patient is a minor, the account can be discussed
   with the patient’s guardian. Care is always taken to identify the patient. The only
   exceptions to this rule include discussing the case with the payer of service in
   order to get the patients account paid and with legal council if the claim is in
   litigation. Failure of an employee to maintain confidentiality is grounds for
   immediate dismissal.
7. Duplicate billing is not permitted by any employee of ___________________.
   __________________________ adheres to all federal and state regulations for
   submitting medical claims. Two (2) or more carriers are never billed for the same
   date of service or duplicate procedures on the same date of service. The patients
   identified primary carrier is billed only once. See billing policies and procedures
   section for detailed billing guidelines.
8. ________________________________________ compensates its employees at an
   appropriate salary determined by the employee’s level of experience and
   education. It does not compensate employees by any monetary incentive with the
   promise of increased cash flow.
9. _______________________________________ cautions our physicians regarding
   giving discounts for services rendered. All physicians are aware that they could be
   in serious non-compliance if they waive patient’s co pays and deductible amounts
   as deemed by the carrier. Only patients who have signed an indigent waiver and
   shown proof of financial hardship are given any type of professional discount or
10. ____________________________________ is committed to appropriate coding for
   all services billed by our physicians. Continuing education is a requirement of all
   of our billing staff. This is achieved by attendance at seminars, and or course
   materials for home study or college class work.

11. __________________________________ keeps copies of all seminar attendance,
   certification, disciplinary action, performance reviews and any training materials
   in each employees personnel file.
12. A phone line has been established, as suggested by the OIG, in order to prevent or
   report fraud and abuse. This phone number is posted in the office and is available
   to all employees. Reports and or complaints and any resulting investigation are
   acted upon if necessary, and/or reported to the appropriate authorities. All reports
   are kept in a confidential file in the Billing office.
13. The compliance officer/committee is responsible for the direct training or
   delegation of training on all compliance procedures/ all employees of
   _________________________ are informed that strict observance of all
   procedures set forth in this manual are a condition of continued employment.
   Failure to comply results in corrective disciplinary action, which is documented in
   the form of a written warning. If behavior is repeated, or employee continues to
   exhibit non-compliant behavior, immediate termination of the employee will
                                  Practice Name
                    Compliance Training and Education

1. All employees of ___________________________________ are required to
   attend an initial overall training session reviewing our compliance plan.
2. All employees will be responsible for reporting any non-compliant activity by any
   of their co-workers and or activity by a provider of service directly to the
   Compliance Officer and committee who will investigate and proceed with a step-
   by-step disciplinary action.
3. Each employee of ____________________________ will receive a copy of the
   compliance plan. A signed affidavit stating that it was received, read and
   understood will be kept in the employee’s individual personnel file.
4. All Billing employees of ______________________________ are required each
   calendar year to complete 8-16 hours of continuing education. Education can be
   in the form of attendance at a seminar, an outside facility or in-house training with
   material purchased from educational facilities specializing in coding, billing, and
   Family Practice, Internal Medicine and Pediatrics or medical information.
5. New employees all begin with basic training which includes but is not limited to
   the following:
   a).     All federal and state regulations (see handout compliance manual)
   b).     How to read an insurance card.
   c).     How to use an ICD-9 and CPT reference manual.
   d).     Where to look for or who to go to for medical information that maybe
   e).     Intensive training on how and when to use modifiers.
   f).     How to read an EOB.
   g).     Review of E& M coding guidelines (billing staff) 1995/1997
6. All billing and training materials including any coding changes, are kept in
   binders within the office. This information is always available to all employees at
   anytime to reference if they should have any questions or concerns on why a
   particular code was billed.
7. Any violations, regarding coding issues are addressed by the compliance officer,
   any employee who willfully changes or modifies a code, or refuses to follow the
   practices policies and procedures regarding collections and billing are to be
   disciplined as follows:
                  a). a verbal warning with training on problem area
                  b). a written warning with additional training and a 30 day
                     probation period.
                  c). third offense results in termination of employment.
                                Practice Name
                           Auditing and Monitoring

1. The ____________________________ monitors and reviews elements of our
   compliance program. This audit is done to determine whether or not all
   compliance elements have been met.
2. The review process includes but is not limited to the following:
       1.) Testing of billing and coding staff on knowledge of reimbursement
           and coverage.
       2.) Yearly review of a sample of at least 10 charts per physician to verify
           documentation for E&M codes for both inpatient and out patient
       3.) Examination of complaint log.
       4.) Yearly evaluation of employees and checking of personnel records for
           proper documentation to support level of continuing education for
           billing personnel.
3. The compliance office will complete all Reviews; if the compliance officer
   finds credible evidence of misconduct the disciplinary process will begin and
   be documented in the employees personnel file. If the compliance officer feels
   that the misconduct may violate criminal or civil law, the officer will report
   the misconduct promptly to the board of directors of the practice.
4. If the compliance officer discovers credible evidence of continued
   misconduct, fraud or abuse the compliance officer will make sure that:

              1). No false claims are submitted to any carrier.
              2). Report misconduct to appropriate authorities, within 60 days
              after determining there is credible evidence of a violation.
                                Practice Name
                   List of Available Resources and Training Materials

____________________________ maintains current resource books including but
not limited to the following:

      CPT Manuals
      ICD-9 Manuals
      Medicare Carrier Bulletins
      Blue Shield PRN Bulletins
      Family Practice Coding Alerts
      Part B Medicare Publication
      PDR
      Medical Dictionary
      UPIN Directories (on-line)
      Correct Coding Initiative and Updates (on CD)

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