Facility Compliance Plan
University Of Missouri Health Care System
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Table of Contents
Topic Page Number
Introduction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03 I. II. III. IV. V. VI. VII. Standards of Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06 Designating Compliance Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06 Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .06 Maintaining Resource Line (Hot Line) . . . . . . . . . . . . . . . . . . . . . . . . . . . .07 Investigate All Reports of Non-Compliance . . . . . . . . . . . . . . . . . . . . . . . .07 Internal Auditing and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .08 Systematic Problems and Development of Policies . . . . . . . . . . . . . . . . . . 11
Appendix 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.
INTRODUCTION 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) arei. ii. iii. iv. v. vi. Hospital – Jointly: Mike Lynch and Darlene Ornburn (884-0632) Professional Services (PS) – Darlene Ornburn (882-3295) School of Medicine (SOM) – Susan Koenig (882-2460) School of Nursing (SON) – Patti Wright (882-0756) School of Health Professions (SHP) – Beth Hays (882-8425) 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. 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.
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Acronyms: 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). Reporting 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
I.
STANDARDS OF CONDUCT AND POLICIES AND PROCEDURES
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/.
II. DESIGNATED COMPLIANCE OFFICERS 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.
III. EDUCATION AND TRAINING 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: http://muhealth.org/~compliance 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.
IV. MAINTAINING RESOURCE (HOT LINE) 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.
V. INVESTIGATE ALL REPORTS OF POSSIBLE VIOLATIONS 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 processes.
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VI.
INTERNAL AUDITING AND MONITORING
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 distributed. 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 compliance. 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 practices. 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.
VII.
SYSTEMIC PROBLEMS AND DEVELOPMENT OF POLICIES
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 claims. 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 occur. 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 performed. 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 noncompliance 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 compliance. 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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APPENDIX
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Audit Schedule (proposed) 2007-2008 AUGUST 2007 Professional Pathology Radiology Oversight/Quality Control OB/GYN APRN Follow-up FCM/Surgery/Dermatology Oversight/Quality Control OB/GYN Ophthalmology Child Health Oversight/Quality Control Facility Source of Admission Code/Discharge Disposition
September 2007 Medical Necessity Survey Main OR observation x2
October 2007 CRH- IRF Unit Clerk Medical Necessity Training Development of med. nec. screen savers High Dollar Endoscopy Observation x1 November 2007 University Physician- Radiology Orders IV Therapy/Services 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 Ambulance Billing Follow-Up One Day Stay vs. OBS 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 Cardiac Rehabilitation Follow-up GI Lab Follow-up th DME (supplies) 4 floor Clinic Review x3 (Wound clinic, Fairview clinics) OR observations
Internal Medicine Child Health Oversight/Quality Control
Internal Medicine Follow-up Pathology Oversight/Quality Control
PM&R Neurology ENT Follow-up Psychology/Radiology
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Audit Schedule (proposed) 2007-2008 (continued) February 2008 Modifier 25 IV Therapy/Services follow-up Conscious Sedation Follow-up Clinic Review x3 March 2008 Medicare Secondary Payer P&O Audit, Clinic Review x3 Follow-up Reviews April 2008 DRG Same Day Re-Adm. Clinic Review x3 Follow-up Reviews
Anesthesiology Follow-up OB-Gyn/Child Health Oversight/Quality Control
Family and Community Medicine Oversight/Quality Control
ER Surgery Follow-up Internal Medicine Oversight/Quality Control
May 2008 Pathology Inpatient Hosp pmts for New Technologies 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 Control Facility Tentative: Payments to Organ Procurement Organizations Orthopaedics Follow-up Anesthesiology Oversight/Quality Control
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2008 UMHC COMPLIANCE EDUCATION PROGRAM 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 Residents and medical students Department Administrators Hospital Associate Directors Physician coding and billing staff
Hospital coding and billing staff Hospital department managers New staff for any of the above positions
DEFINITION OF COMPLIANCE EDUCATION AND EDUCATION FOR UMHC 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.
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EDUCATION IMPLEMENTATION PLAN Identified Education Needs Education needs will be identified through: Compliance Reporting Line calls Risk Assessment Tool Automated Audit Tool Payer bulletins Program memorandums OIG Workplan
Questions received from employees Provider and employee requests Information from audits (both E/M documentation audits and other types of audits)
Education Plan Design Groups have been identified for targeted education (see Education for Targeted Audiences section). 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 accessibility. 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 scenarios. Provide education as scheduled as well and in response to impromptu requests
EVALUATE EDUCATION FOR EFFECTIVENESS 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 information. 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 job. 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 effect.
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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 EDUCATION IN DATABASE & IN PAPER FILE 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.) EDUCATION FOR TARGETED AUDIENCES Compliance Education for Physicians Corporate Compliance Physicians at Teaching Hospital guidelines (PATH) E/M Documentation Guidelines Non-physician billing Medical necessity / ABN Modifiers Observation Codes 72-hour Rule Pneumonia Upcoding
Stark Laws Kickback regulations Exclusion rules Verbal orders Completion of the medical record Signatures HIPAA Corporate Compliance
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
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FACILITY COMPLIANCE PLAN - 2008
Compliance Education for Billers and Coders Corporate Compliance Physicians at Teaching Hospital guidelines Fraud and Abuse E/M Documentation Guidelines Modifiers Hospital Department Managers Corporate Compliance Medicare Intermediary guidelines Medical Necessity / ABN and HINN Observation Codes 72-Hour Rule Kickback regulations Exclusion rules Verbal orders All Other Members of the Workforce HIPAA Code of Conduct
Observations Codes 72-Hour Rule Non-physician billing Medical Necessity HIPAA
Signatures MSP Survey Non-physician billing Overpayments Fraud and Abuse Handling of complaints HIPAA
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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”)
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Reason: Confused for one another. Can mean morphine sulfate or magnesium sulfate. For the full JCAHO explanation click on: http://www.jcaho.org/accredited+organizations/patient+safety/04+npsg/04_faqs.htm Policy MOI-07: Abbreviations in the Medical Records may be read at: http://docushare.umh.edu/dsweb/View/Collection-1447
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