Facility Compliance Plan 2008

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					                     Facility Compliance Plan

      University Of Missouri Health Care System

Version 3, 12/2007              1
                                                   Table of Contents
                    Topic                                                                                           Page Number

      Introduction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03

      I.            Standards of Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06

      II.           Designating Compliance Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06

      III.          Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .06

      IV.           Maintaining Resource Line (Hot Line) . . . . . . . . . . . . . . . . . . . . . . . . . . . .07

      V.            Investigate All Reports of Non-Compliance . . . . . . . . . . . . . . . . . . . . . . . .07

      VI.           Internal Auditing and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .08

      VII.          Systematic Problems and Development of Policies . . . . . . . . . . . . . . . . . . 11


                   Proposed Schedule for 2008. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

                   Compliance Education Program 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

                   Approved Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

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                         Office of Corporate Compliance
                     Facility (Hospital) Compliance Plan 2008

     This Compliance Plan applies to all University of Missouri Health Care (UMHC) facilities.


The United States Sentencing Commission defines a compliance program as “a program that has
been reasonably designed, implemented, and enforced so that it generally will be effective in
preventing and detecting criminal conduct. Failure to prevent or detect the instant offense, by
itself, does not mean that the program is not effective. The hallmark of an effective program to
prevent and detect violations of law is that the organization exercise due diligence in seeking to
prevent and detect criminal conduct by its workforce members or other agents.”

This program is a voluntary compliance plan that focuses on several areas and aspects of the
health care industry. We believe that the development and implementation of our compliance
program guidance for the University Health Care System well serve as a positive step in assisting
UMHC facilities in preventing the submission of erroneous claims and/or engaging in unlawful
conduct involving the Federal healthcare programs as well as commercial payer programs. This
is accomplished by utilizing internal controls to efficiently monitor adherence to applicable
statutes, regulations and program requirements.

This compliance plan is intended to provide specific direction to our facilities and health care
providers. Our compliance program will provide a solid basis upon which to build a compliant
environment by following the seven components of an effective facility compliance program as
outlined by the Office of Inspector General (OIG). Those seven components are:

    I.   Practice of Standards and Policy and Procedures, Code of conduct as well as policies
         and procedures are located on a UMHC internal web-site and available to all faculty, staff
         and students;

    II. Appoint Compliance Officers, UMHC employed Mike Lynch, MPA as Chief Compliance
        Officer (CCO). Operating Unit Compliance Officers (CO) are-

                        i.   Hospital – Jointly: Mike Lynch and Darlene Ornburn (884-0632)
                       ii.   Professional Services (PS) – Darlene Ornburn (882-3295)
                      iii.   School of Medicine (SOM) – Susan Koenig (882-2460)
                      iv.    School of Nursing (SON) – Patti Wright (882-0756)
                       v.    School of Health Professions (SHP) – Beth Hays (882-8425)
                      vi.    Institutional Review Board(IRB)– Michele Kennett (882-3182)

    III. Education and Training, quarterly education sessions are open to all workforce
         members. New workforce orientation and new provider orientation as well as many other
         topics are available through in-service, web-based and individualized training;

    IV. Maintaining resource (hot-line) for which staff may report possible violations through
        24-hour paging, reporting line in addition to personal contact with CCO and unit COs;

    V. Investigate all reports of possible violations, all reports are investigated and reported
       to Executive Compliance Committee (ECC) or senior management according to the
       protocol established in this plan; and,

    VI. Internal Audit, audit reports assist management in identifying where there are potential
        problems, as well as recommendations for corrective action; and,

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    VII. Systemic problems and development of policies, managers are required to develop a
         plan to address negative findings, with modifications of existing policies or the
         development of new policies to correct non-compliant activity.

This document has been approved by the UMHC Executive Compliance Committee (ECC), of
which the University Hospital, Columbia Regional Hospital, Ellis Fischel Hospital, the UP Practice
Management Group, the Deans of SOM, SON, SHP and MRC have designed representation.
This plan is revised annually, or as needed based as governmental rules changes. The most
current official Facility Compliance Plan is located on DocuShare as a part of the overall
Corporate Compliance Plan at https://docs.hsc.missouri.edu/dscgi/ds.py/View/Collection-459.

If you have any questions concerning this Compliance Plan, please contact the Office of
Corporate Compliance at 573-884-0632 or Darlene Ornburn at 573-882-3295.

Terms Utilized in this Document

            o    The term “University of Missouri Health Care System (UMHC)” in this document
                 refers to University of Missouri Hospital (UH); Community Health Clinics;
                 Missouri Rehabilitation Center (MRC); Columbia Regional Hospital (CRH); Ellis
                 Fischel Hospital; and Children‟s Hospital to include those professional service
                 members who provide health care to our patients.
            o    The term “workforce” as used in this plan applies to all healthcare providers,
                 staff, students, residents, volunteers or contractors of the University of Missouri
                 Health Care System and their entities.

           o Facility (Hospital) Compliance Plan – „the Plan‟.
           o The Office of Corporate Compliance – OCC
           o Chief Compliance Officer – CCO
           o Professional Services Compliance Officer - CO
           o Centers for Medicare and Medicaid Services – CMS
           o Office of Inspector General – OIG
           o Executive Compliance Committee - ECC
           o University Physicians & University Physicians Practice Management Group – UP

Policy Guidance

    The CCO or CO will provide oversight and serve as an advisor for development of policies for
    departments as related to reimbursement/submission of billing with Centers for Medicare &
    Medicaid Services‟ (CMS) regulations. Those regulations include (but not limited to)
    regulations associated with documentation issues in an effort to avoid overpayment situations
    for government payers as well as State of Missouri‟s statues and each facility‟s Bylaws. The
    CCO/CO will ensure our workforce have the opportunity to review the criteria as designed
    within this plan; and that they attest to their knowledge, understanding of, and agreement to
    comply with said policies and regulations. UMHC coding and billing staff will be asked to sign
    an acknowledgment card stating that they understand it is their responsibility to report
    possible non-compliant activity associated with claims submission.

    Facility billing and related areas of compliance oversight will be the responsibility of the
    CCO/CO and/or assignee. Therefore, OCC has the authority to access all information
    necessary to ensure appropriate auditing / monitoring of facility fee billing and may utilize
    internal or external legal counsel as necessary. (See Corporate Compliance Policy CC-1.).

    The CO will report issues requiring corrective action to the Executive Compliance Committee,
    as necessary. The CO will participate in the Compliance Forum as a member and on the
    Executive Compliance Committee as a non-voting member. The CO will also convene any ad

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    hoc committee(s) as deemed necessary to attain overall compliance within the claims
    submission arena. (example: risk assessment committee).

    The CCO will provide at least annual reports to the Executive Compliance Committee and to
    the CEO describing non-compliant activities identified, and actions taken to correct those
    issues. Corrective actions may include; educational programs, additional auditing/monitoring
    processes, and/or recommendations for on-going correction. For those non-compliant issues,
    a corrective action report will be forwarded to the CEO, Director of the facility involved and/or
    other senior management team as appropriate.
    Service line/department specific reports will be provided to the manager and their associate
    director. For those non-compliant activities that require immediate attention, the CEO, CFO
    and/or senior management along with counsel‟s office will be notified. Other individuals may
    be included when necessary to protect our health care system.

Ongoing Maintenance of the Plan

    Ongoing maintenance for the Plan will include development of additional components and/or
    revision to any portion of the Plan due to changes in the government rules, regulations and
    guidance and/or the way we conduct business and/or other unforeseen items.
    Any modifications to the compliance program which are necessary to ensure conformance
    with legal and regulatory standards must be approved by the ECC either at a regularly
    scheduled meeting or by an electronic vote of the majority.

Compliance Committees:

    The Executive Compliance Committee consists of the chairperson, the Chief Compliance
    Officer (CCO), and voting members. Voting members are the Chief Executive Officer (CEO);
    Chief Financial Officer (CFO), Chief Operating Officer (COO), MRC Director, Chief Quality
    Officer, UP Practice Chairman/Director, Dean of School of Medicine, Dean of School of
    Nursing, Dean of School of Health Professions, and legal counsel serving in ex-officio
    capacity. The PS Compliance Officer will also attend as non-voting member. The ECC
    meets on a quarterly basis with emergency sessions as necessary.

    The Compliance Forum consists of Compliance Officers from each of the operating units
    along with the HIPAA Privacy and Security Officer and the IRB Compliance Officer. The
    CCO will serve as Chair. Each member is expected to report issues and/or concerns to this
    Forum for discussion. Recommendations on issues or concerns may be developed and
    presented to the ECC for action. The Forum will meet monthly except for those months when
    the ECC meets.

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                                   THE FACILITY COMPLIANCE PLAN


The UMHC has implemented a formal „Code of Conduct‟ that must be renewed on an annual
basis. Each faculty, professional and staff member is required to annually demonstrate their
proficiency for the code of conduct by on-line testing or attending an in-service educational
session. New faculty, professional and staff are provided the Code of Conduct during orientation
and required to attend an in-person presentation or to be tested on-line.
The on-line address for physicians, residents and Non-physician Practitioner‟s is:
http://umhc.ehealthcareit.net/ and select Code of Conduct. This takes about 15 minutes to
complete and is an annual requirement. Scores will be recorded automatically, no further action is
required. For other workforce, the on-line address is: http://ced.muhealth.org/
Coding standards are established and are posted on the DocuShare (shared drive), all staff have
access to this information at https://docushare.umh.edu/dsweb/View/Collection-2018.
DocuShare also contains a link to the University Collected Rules where workforce is encouraged
to review and follow all guidances. These may be reviewed at
https://docushare.umh.edu/dsweb/View/Collection-142. Each facility has Medical Staff Bylaws
that must be reviewed and followed as well. Bylaws and rules and regulations may be reviewed
on DocuShare at https://docushare.umh.edu/dsweb/.


The Chief Compliance Officer is Mike Lynch, MPA. He provides direct oversight of the Office of
Corporate Compliance staff and performs a coordinating role for the operating unit compliance
officers listed on page 3. Responsibility for facility compliance activities is shared by the CCO and
the CO.
The CO is Darlene Ornburn, PhD and has a relationship with Missouri Rehabilitation Center
(MRC) in their professional and facility billing compliance activities. She has direct oversight of
compliance auditing related to claims submission, investigation of non-compliant activity,
processes and procedures, related to CMS, OIG and other regulatory guidance.


The CCO/CO assumes the responsibility in the development of curricula to address practice
management issues to include, training for hospital administration, medical staff, department
managers, staff and volunteers of UMHC. Educational programs will focus on the educational
needs specific to facility compliance.

Mandatory education for all staff working within the UMHC facilities includes the „Code of
Conduct‟. Code of Conduct material is distributed by OCC and is updated annually. Compliance
proficiency testing is required of all workforce who work at the UMHC.

        Code of Conduct material is distributed by OCC and is updated annually. Testing is
        required of all employees, faculty and professional staff who work at the University
        Healthcare System. See section on Code of Conduct.
The Compliance Office staff will respond to other educational needs through a quarterly open
education for all workforce. OCC will continue to provide monthly education sessions for the
coding and billing staff, as well as encourage in-person and electronic learning whenever
possible. Our office also publishes a monthly electronic newsletter that addresses changes in the
regulatory environment as well as prints articles that relate to questions asked of our analysts.

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Compliance education program proposed for year 2008 may be reviewed beginning on page 16
of this document. This program in its entirety may be viewed on our web-site:

The OCC staff will review information and/or materials received from workshops, seminars and
teleconferences prior to implementation. Contact the OCC office when such information is
received at 884-0632.


The OCC provides a mechanism for workforce members to raise questions and receive
appropriate guidance concerning facility billing and compliance concerns.
       Compliance “hot line” (573-884-1729)
       Toll free “hot line” (877-201-3146)
       University of Missouri “hot line” (866-447-9821)
       24-hour pager (573-441-7837)
       Contact the Chief Compliance Officer on cell 819-0309
       Contact the PS Compliance Officer (573-882-3295)
       Email lynchm@health.missouri.edu or ornburne@health.missouri.edu

OCC conducts interviews and compliance discussions throughout the year and encourages staff
to be proactive in reporting possible non-compliant activity. Our reporting numbers and contact
information is distributed on note pad, pens, various tools developed, business cards, and during
presentations, etc.


The OCC will respond to all reports received on suspected non-compliance by initiating an
appropriate investigation. The investigations may be performed in cooperation with other
divisions and/or departments within the UMHC as deemed appropriate by the CCO and/or CO.

Workforce may be subject to disciplinary action, when or if they are directly responsible for
violation of billing standards, or when they are responsible for detecting conduct by another
individual who violates the billing standards, of which they could have “reasonably been
expected” to detect such behavior. Any workforce member who identifies a non-compliant activity
should immediately contact their manager, supervisor, the compliance office, or call the resource
line/ 24-hour paging number. (See Policy CC1 and CC7.)
All such reports will be held in confidence and every effort will be made to protect the identity of
the reporter. No retaliatory action will be taken against any workforce member for reporting in
good faith possible compliance violations. (See Corporate Compliance Policy CC-3).
Once an issue is reported and identified as a possible non-compliant issue, the CCO/CO will
perform or arrange for an investigation with a report of findings to be shared with members of the
ECC and/or other senior management, as appropriate.
When an investigation is identified to be of a grievous nature, the ECC membership, in
collaboration with appropriate senior leadership and/or legal counsel, may make recommendation
on a process for corrective action. Less severe violations will follow OCC‟s routine audit

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The OCC objective is to establish an ongoing integrated evaluation process in an effort to
establish standards and procedures that are current and accurate, and will also assist in ensuring
that the compliance program is working. The OCC‟s goal is to identify areas within the
organization at risk for noncompliance with state and federal regulations through internal audits.
The OCC performs two types of audits in accordance with the Office of Inspector General (OIG)
Effective Compliance Guidance:

          1. Regulations and standards
          2. Claims submission review

The facility compliance program also participates and assists in HIPAA compliance reviews.

                  Note: Our analysts apply a modified version of the OIG’s Auditing Standards as
                  the basis for all audits undertaken.

General Standards for Auditing

There are four general standards for conducting audits that apply to UMHC facilities:

      1. Qualifications of OCC auditors:
         OCC auditors are experienced, knowledgeable and skilled in the areas necessary to
         conduct audits. OCC auditors are professionally certified in quality, coding and
         compliance standards. OCC auditors receive continuing education each year to maintain
         their professional skills and knowledge necessary to conduct audits.

      2. Independence is maintained in all audits processed through OCC.
         OCC auditors are responsible for maintaining independence so that opinions, judgments,
         and recommendations are viewed as impartial by third parties. Audit staff is located
         organizationally at the corporate level and do not report to service lines, departments or
         divisions being audited.

                  Note: Should an auditor have an apparent conflict of interest, he or she will
                  withdraw from the audit.

      3. Due Professional Care is taken on all audit processes:
         The OCC uses auditing principals in accordance with generally accepted government
         auditing standards and are reflected in audit reports. It is also the responsibility of the
         auditor to use sound professional judgment in determining standards that apply to
         specific topics under investigation.

                  Note: Our audit team meets prior to beginning an audit process to research any
                  new or revised rule associated with the audit criteria.

      4. Quality Control is conducted on all audit findings:
         The OCC has an internal quality control process to assure that it has adopted and is
         following applicable audit standards, policies, procedures, and also undergoes quality
         control standards to assure accuracy of the information being collected, analyzed and

                  Note: All findings are evaluated to assure they meet required elements with
                  federal, state and local guidelines. When there is a question, assistance is
                  sought from legal counsel, or other regulatory representative.

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The OCC utilizes four variations of audit processes. These include but are not limited to:

    1. Routine Audits encompass multiple regulatory issues within a single hospital service line,
       clinical department, division or clinic. OCC periodically audits each unit within UMHC.
       During this process, we analyze claims submission, templates are reviewed, interviews
       are conducted with key staff members, and audits are performed for HIPAA compliance.

    2. Tracer Audits look at an individual patient throughout the course of a hospital inpatient
       admission. Patient records for this audit will be collected according to the nursing unit to
       which the patient was originally admitted. Information reviewed may include an itemized
       bill, medical records, pharmacy records, medication records, electronic medical record,
       hard copy medical record, and other billing information. Interviews may be conducted
       with key workforce members involved in the care or billing of this patient.

    3. Focused Audit are initiated by complaint, request, findings from another classification of
       audit, or emerging issues or trends as seen in industry journals or CMS advisories. The
       scope of these audits is specific to the concerns identified.

    4. Follow-Up Audits are audits performed for which a CAP was accepted by OCC for a
       previous audit. This allows OCC overview and oversight of the monitoring process, and
       assures that appropriate interventions or corrective actions were implemented and are
       effective. Follow-up reports will be developed and provided to leadership previously
       identified. Continued negative findings will need to be addressed in a revised CAP
       modified by the service line, department/division. The CAP must be submitted to OCC for
       approval. The OCC will work closely with the service line, department/division to assure
       compliance has been achieved.

    5. Regulatory Audits are determined annually by OCC administration, or by CMS as
       required under any future Plans of Corrections filed in response to a CMS survey. Other
       Regulatory Agencies may request audits be conducted to assure compliance with rules
       and regulations. These audits are specific to the concerns identified.

Finding and Observation Report

A report with our findings and observations will be provided to the service line,
Department/Division Manager, Department Chair(s), and/or Senior Staff. All negative findings
identified within a service line, department/division are required to be addressed in a CAP that is
developed by the service line, department/division. The CAP must be submitted to OCC for
approval. OCC works with the department on education and development of tools to assist with

        Note: After implementation of corrective action plans, a follow-up audit will be conducted
        to assure compliance has been achieved. If areas of non compliance continue, a
        modified corrective action plan must be submitted to the OCC addressing the areas of
        continued noncompliance followed by another audit. The OCC will work closely with
        these department and divisions to correct the areas of continued non-compliance.

Steps for Facility Audits

The OCC developed standardized processes for the development of the focus and scope of
facility audits. The audit plan is the first step in an audit after the issue or topic has been
established. Regardless of the type of audit being undertaken, universal audit steps are
developed to assist with the development, implementation and monitoring of compliance issues
and topics. The steps are as follows:

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Development of Audit Plan
    Issue identified for investigation. Issues can be identified in various ways that may
       include but are not limited to complaints, requests, new guidelines or regulations,
       resource line, OIG work plan, findings or observations from another project, probe audits,
       change in rules or regulations, mandated by government agency or identified by billing
    Audit team assigned and discussion group meets to formulate audit plan. Once a topic or
       issue is identified, a Team Leader is assigned to the issue. The Facility Team meets to
       discuss and make plans to develop and research the risks.
    Research topic for current policies, procedures, best practices, federal and state
       regulations, rules and/or laws. Researching the issues to identify rules, regulations and
       best practice is of paramount importance to the validity of the project. Each issue must
       have consensus documentation or other reliable source of information to support the
       billing and/or issues identified as noncompliant.
    Sample methodology identified. Sample methodology is identified by Team members
       with input from several other stake holders. As part of the planning process, the Team
       must identify the population, sample sizes, randomization, data sources, facilities and
       patient types.
    Audit criteria developed and tested to capture to objectives of the project. In some cases
       where data can not be captured from claims or billing information, a data abstraction tool
       specific to the topic must be developed. The development of the tool is based on the
       research, and scope of the issue identified. After the tool is developed, it is tested on a
       small number of cases to assure the information being captured will accurately reflect the
       scope of the project.

Implementation of Audit Plan
    Perform random sampling of identified issue; obtain medical records, billing information
      and/or any other appropriate audit information.
    Perform audit as outlined in the project plan as described above.
    Quality control/assurance is undertaken on a sample of cases or audit information being
      used for the audit to assure validity of the information. This is performed by the analysts
      who did not perform the original data abstraction. A comparison of the results is
      undertaken by Team to assure validity. If a discrepancy exists, the CO will review all
      information to make the determination of validity.
    Report development by Team Leader. The Team Leader will develop the report with
      input from the Team. The report will consist of an executive summary, background,
      scope, methodology, findings, recommendations and a detailed list of items reviewed or
      actual copies of the supporting documentation.
    Education is an essential part of our auditing process and is based on the results of our
      audit findings. A face to face meeting with service line/department managers and other
      appropriate staff are conducted.
           o If non-compliant activities were identified, a CAP is required to address each of
               those activities.

Monitoring of Audit Results
    Post Audit Monitoring will usually be performed by the service line, department or division
       responsible for non compliance activity. The OCC will request a copy of their written
       report thirty days after implementation of their intervention activities outlined in their CAP.
       Based on the results of that report, additional monitoring may be conducted. In addition,
       the OCC may pull a sample of the cases included in the follow-up analysis to verify the
       information in the report.
    Follow-up Monitoring will be performed by the OCC once interventions and corrective
       action has been accomplished to verify compliance. If areas of noncompliance remain
       after the initial CAP, a revised CAP, following OCC audit, will be required to address the
       areas of continued noncompliance. At this point, OCC will work closely with the service
       line, department or division to correct the deficiency.

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External Audits

The OCC has the responsibility to provide oversight for all billing audits and/or reviews where a
service line, Department and/or Division within the UMHC System engaged external auditors or
consultants. The service lines, departments and/or divisions must forward a copy of the written
report of their findings to the OCC.


Investigation findings will be documented through written reports. The ECC will be provided a
brief overview of our findings, and detailed information will be provided to the appropriate senior
leadership, management or administrative personnel. As necessary, the CCO/CO will work in
cooperation with legal counsel and corporate administration on issues that require mandatory
reporting to governmental agencies. Reports of flagrant or intentional non-compliance will be
sent to the ECC through the CCO. Those less severe findings will be handled by the CCO/CO
with advice from senior management and/or legal counsel, as needed.

Based on the results of the investigational findings, several activities may be initiated to assist
with correcting identified deficiency. Based on the severity of the deficiency, one or more of the
following interventions may be instituted. These interventions are based on proven industry-wide
intervention techniques.

Types of interventional activities may include the following for less severe issues:
     Repayment of all overpayments
     Deficiency meeting or group meeting to discuss findings and observations on
        noncompliant issues. Meetings will include service line, department/division
        management, supervisors, other key staff and from the OCC Project Team, Compliance
        Administrator and Director of Compliance.
     Education (e.g., new workforce orientation, one-on-one education, group education,
        screen savers, flyers, posters, online courses.) Education will also be topic/issue
        specific to the deficiency identified.
     Work groups/Taskforce may be convened to focus on a particular process that may
        cross several service lines, departments/divisions. Workgroups will assist in developing
        a resolution to the identified issue.
     Root cause analysis may be performed to identify systematic problems and develop a
        corrective action plan.
     Mentorship/shadowing: Mentorship is one-on-one education by a workforce member
        who may be considered an expert in the field and is willing to share their knowledge.
        Shadowing is a process where one person follows another person who provides
        education on proper techniques.

More severe issues identified may require intervention or consequences, to include:
    Warnings (written/verbal)
    Probation
    Suspension
    Termination
    Mandatory reporting to Government Agencies. This is only cases requiring mandatory
       reporting or issues that may be identified that should be self reported.
    Repayment of monies to Government Agencies if UMHC was found to submit inaccurate
    Self-reporting to criminal and/or civil law enforcement authorities
    Self-reporting to licensing or credentialing agencies in areas with gross or flagrant fraud
       and/or abuse

The OCC will request a CAP for all confirmed deficiencies identified. An effective CAP should be
based on the principals of quality improvement. The CAP should include the following:

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       Deficiency identified (area identified through the audit review and analysis)
       Steps to correct the deficiency must be identified after thorough evaluation of the current
        process. This allows identifying processes that needs to be changed for the correction to
       Responsibly party(s) must be identified who will assume responsibility for the actions
        being undertaken. This provides the OCC with a consistent contact.
       Timeline for implementation and monitoring is also an integral part of the plan. Timeline
        should include milestones and implementation timeline on when activities should be
       Monitoring process should address how modified processes are going to be internally
        monitored to assure compliance.
       Results must be forwarded to the OCC for review and oversight. A copy is maintained in
        the OCC file.

As part of the department‟s internal monitoring process, the OCC will request written copies of the
results of the department‟s monitoring process and any outside audit report.

If non-compliance continues, additional education will be provided by the OCC and the
appropriate hospital associate director will be notified in a detailed written report. Continued non-
compliance will result in notification to the CEO through a detailed report of the issues and of prior
corrective actions taken.

Intentional violations or high risk violations will immediately be reported to ECC and the
appropriate hospital administrator and/or department chairperson, legal counsel, Director of
Compliance and the CEO for action. After the initial intervention, the OCC analyst will monitor for

In the event that the CCO/CO has a conflict of interest with the subject of an investigation, the
ECC will designate an individual who will assume the investigative role.

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                                    Audit Schedule (proposed)

                                          AUGUST 2007
                     Professional                                         Facility
Pathology                                           Source of Admission Code/Discharge Disposition
Oversight/Quality Control
                                         September 2007
OB/GYN                                          Medical Necessity Survey
APRN                                            Main OR observation x2
Follow-up FCM/Surgery/Dermatology
Oversight/Quality Control
                                          October 2007
OB/GYN                                           CRH- IRF
Ophthalmology                                    Unit Clerk Medical Necessity Training
Child Health                                     Development of med. nec. screen savers
Oversight/Quality Control                        High Dollar
                                                 Endoscopy Observation x1
                                         November 2007
Internal Medicine                                University Physician- Radiology Orders
Child Health                                     IV Therapy/Services
Oversight/Quality Control                        Orthopaedic Peak Performance PT inquiry
                                                 Travel Policy & Procedure Audit
                                                 Advanced Beneficiary Notices/Polysomnography
                                                 Main OR x2 & SDSC x1
                                                 Unit Clerk Medical Necessity Training x2 sessions
                                         December 2007
Internal Medicine                                Ambulance Billing Follow-Up
Follow-up Pathology                              One Day Stay vs. OBS
Oversight/Quality Control                        CRH- ER
                                                 CRH- PoO (POA/DC dis.)
                                                 Clinic Reviews- x3 (FCM- Keene St. x2, Pre-Op clinic)
                                                 OR observations
                                                 Unit Clerk Medical Necessity Training x2 sessions
                                          January 2008
PM&R                                             Cardiac Rehabilitation Follow-up
Neurology                                        GI Lab Follow-up
ENT                                              DME (supplies) 4 floor
Follow-up Psychology/Radiology                   Clinic Review x3 (Wound clinic, Fairview clinics)
                                                 OR observations

        Version 3, 12/2007                     14
                                      Audit Schedule (proposed)
                                        2007-2008 (continued)

                                            February 2008
Anesthesiology                                        Modifier 25
Follow-up OB-Gyn/Child Health                         IV Therapy/Services follow-up
Oversight/Quality Control                              Conscious Sedation Follow-up
                                                      Clinic Review x3
                                             March 2008
Family and Community Medicine                         Medicare Secondary Payer
Oversight/Quality Control                             P&O Audit, Clinic Review x3
                                                      Follow-up Reviews
                                              April 2008
ER                                                    DRG
Surgery                                               Same Day Re-Adm.
Follow-up Internal Medicine                           Clinic Review x3
Oversight/Quality Control                              Follow-up Reviews

                                              May 2008
Orthopaedics                                          Pathology
Follow-up Anesthesiology                              Inpatient Hosp pmts for New Technologies
Oversight/Quality Control                             Clinic Review x3
                                                       Follow-up Reviews
                                              June 2008
Psych                                                 Dialysis- Inpt vs. OBS
Missouri Rehab Center                                 RACC- Medical Records
Dermatology                                           Clinic Review x3
Follow-up Family and Community Med Oversight/Quality Follow-up Reviews
                                          Facility Tentative: Payments to Organ Procurement Organizations

       Version 3, 12/2007                         15

Education for compliance related issues for targeted and general audiences is available through
the Office of Corporate Compliance (OCC). Education is a component of the overall
comprehensive auditing processes conducted through the OCC as well as a focus area for
ensuring all University of Missouri Health Care workforce members are given applicable
instruction in pertinent compliance issues associated with their work.

The frequency and content of the education will be based on applicable changes and updates to
local, state and federal laws and regulations; organizational policy; and need for education in any
given area. Need is identified through observation of practice, results of OCC auditing and
monitoring, or as expressed by individuals or groups involved in a compliance-related issue.
Recommendations for mandatory or required education are made based on need to meet local,
state, and federal guideline requirements and to become knowledgeable of our own
organizational policies.

Mandatory education includes:

       Code of Conduct
       Documentation guidelines as handed down by the Centers for Medicare and Medicaid
        Services (CMS) for both 1995 and 1997
       UMHC Policies and Procedures
       Certain web-based compliance instruction as required for re-credentialing

Target audiences would include:
     Physicians                                             Hospital coding and billing staff
     Residents and medical students                         Hospital department managers
     Department Administrators                              New staff for any of the above
     Hospital Associate Directors                            positions
     Physician coding and billing staff


Compliance education and education within our organization is defined as:
 In-services as requested
 Pre-scheduled education for targeted groups
 Monthly meetings (e.g. Updates for Coding and Billing Staff)
 Ad hoc meetings
 Seminars
 Distribution of third party payer bulletins and information (e.g. CMS updates, etc.)
 Compliance information on internal website
 On-the-job education (e.g. education provided at the department or clinic level)
 New Staff Orientation
 Telephone conferences with carriers
 Audio-conferences
 Web-based education

A good faith effort will be made to document all education and educational materials so both the
content and the attendee information is easily accessible for both internal and external review.

Version 3, 12/2007                              16
Identified Education Needs
Education needs will be identified through:
 Compliance Reporting Line calls                       Questions received from employees
 Risk Assessment Tool                                  Provider and employee requests
 Automated Audit Tool                                  Information from audits (both E/M
 Payer bulletins                                        documentation audits and other types of
 Program memorandums                                    audits)
 OIG Workplan

Education Plan Design
 Groups have been identified for targeted education (see Education for Targeted Audiences
 A targeted education plan has been developed for these groups. This education is in the
   form of lecture/classroom education and in some cases, computer based education.

Education topics for each group has been identified to target their specific needs (see Education
for Targeted Audiences section).
Education Schedule
 Schedule education dates and times.
 Schedule rooms / locations for education.
 Education could be scheduled so it is frequent, but limited to small components so
     compliance is continuously kept in front of employees.

Curriculum Development
 Identify subject matter.
 Involve subject matter experts to develop content.
 Create appropriate means of delivery; handouts, power point presentations, etc.

Maintain a Central File of Course Materials
 Maintain a central file of the original paper handouts, slides, and overheads for ease of
 Maintain a central file of handouts, slides, overheads, etc. on the shared network drive when
   electronic copies are available.

Provide the Education
 Capture attendance at each event by providing a sign-in sheet.
 Be aware of the audience. Provide the intended information using appropriate examples and
 Provide education as scheduled as well and in response to impromptu requests

 Provide evaluations of the session for staff at the time of education.
 Administer test or ask attendees to provide return demonstrations (where appropriate) so you
   know they understand how to do the task and to indicate that they understood the
 Examine the results of the tests and/or return demonstrations given at the time of the
   education to see if remediation is needed.
 Spot-check with supervisors to see if attendees are using the information effectively on the
 Do follow-up audits to verify education effectiveness.
 Look at trends such as payer denials and follow-up audits to see if education had a positive

Version 3, 12/2007                              2
Provide Corrective Action (as needed)
If education has not been effective, create a corrective action plan. This might include:
 Talk to or survey the participants to identify reasons the information presented has not been
     incorporated into practice.
 Re-educate (if material wasn‟t communicated effectively).
 Evaluate policies for appropriateness.

 Document attendance in the appropriate learning management system to update transcripts
  of individuals in attendance.
 Place sign in sheet in a central file.

Education Reports
 Run education reports on a monthly basis for Compliance Officers, Corporate Compliance
   Officer, Executive Committee, and Administration.
 Run end of year education report.

Assessment and Evaluation of Education Programs
Assessment of the education programs will be ongoing. Suggestions for improving the program
can be derived from several sources such as:
 Feedback through evaluations.
 Audit and reimbursement staff (hospital & UP).
 Compliance Office staff and Corporate Compliance Officer.
 Administration.
 Regulatory standards groups within the organization.
 Other sources (e.g. current information from list serve, OIG work plan, etc.)


Compliance Education for Physicians
Corporate Compliance
Physicians at Teaching Hospital guidelines          Stark Laws
(PATH)                                              Kickback regulations
E/M Documentation Guidelines                        Exclusion rules
Non-physician billing                               Verbal orders
Medical necessity / ABN                             Completion of the medical record
Modifiers                                           Signatures
Observation Codes                                   HIPAA
72-hour Rule                                        Corporate Compliance
Pneumonia Upcoding

Compliance Education for Department Administrators and Hospital Associate Directors
Physicians at Teaching Hospital (PATH)       Signatures
guidelines                                   Overpayments
E/M Documentation Guidelines                 Fraud and Abuse (specific examples e.g.
Non-physician billing                        changing the code for the payment after the
Medical necessity / ABN                      fact)
Modifiers                                    Handling of Complaints (Preventing
Observation Codes                            Whistleblowers)
72-Hour Rule                                 HIPAA
Pneumonia Upcoding
Stark Laws
Kickback regulations
Exclusion rules
Verbal orders
Completion of the medical record

Version 3, 12/2007                             2
                          FACILITY COMPLIANCE PLAN - 2008

Compliance Education for Billers and Coders
Corporate Compliance                          Observations Codes
Physicians at Teaching Hospital guidelines    72-Hour Rule
Fraud and Abuse                               Non-physician billing
E/M Documentation Guidelines                  Medical Necessity
Modifiers                                     HIPAA

Hospital Department Managers
Corporate Compliance                          Signatures
Medicare Intermediary guidelines              MSP Survey
Medical Necessity / ABN and HINN              Non-physician billing
Observation Codes                             Overpayments
72-Hour Rule                                  Fraud and Abuse
Kickback regulations                          Handling of complaints
Exclusion rules                               HIPAA
Verbal orders

All Other Members of the Workforce
Code of Conduct

                             FACILITY COMPLIANCE PLAN - 2008

                                PROHIBITED ABBREVIATIONS

Effective 1-1-2004 JCAHO expects all prescribers and hospital staff to discontinue use of the
following prohibited abbreviations:
 U for unit (write "unit")
          Reason: “U” can be mistaken as zero, four or cc.
 IU for International Unit (write "international unit")
 Reason: “IU” can be mistaken as IV (intravenous) or 10 (ten).
 Q.D. for once daily (write "daily")
 Q.O.D. for every other day (write "every other day")
 Reason: Mistaken for each other. The period after the Q can be mistaken for an "I" and the "O"
          can be mistaken for "I".
 trailing zero (e.g., "2.0 mg") (write "2 mg")
 lack of leading zero (e.g., ".25 mg") (write "0.25 mg)
 Reason: Decimal point is missed.
 MS for either morphine sulfate or magnesium sulfate
 MSO for morphine sulfate (write “morphine sulfate”)
 MgSO for magnesium sulfate (write “magnesium sulfate”)
 Reason: Confused for one another. Can mean morphine sulfate or magnesium sulfate.

For the full JCAHO explanation click on:

Policy MOI-07: Abbreviations in the Medical Records may be read at: