Health Care and Billing Compliance

1. Health Care and Billing Compliance Lesson 4 Medicare Target Areas Section 2

2. Long Term Care

3. OIG Voluntary SNF Program Guidance Issued in March 2000to provide Skilled Nursing Facilities with guidance in developing an internal compliance program Long Term Care THE OFFICE OF INSPECTOR GENERAL COMPLIANCE PROGRAM GUIDANCE FOR SKILLED NURSING FACILITIES March 16, 2000 FR Vol. 65 No. 52

4. Skilled Nursing Facility Minimum Data Sets (MDS)

6. http://www.cms.hhs.gov/quality/mds20/MDSAllForms.pdf

7. http://www.cms.hhs.gov/quality/mds20/MDSAllForms.pdf

8. SCORE Skilled Nursing Facility Resource Utilization Groups (RUGS)

9. Skilled Nursing Facility RUG Creep

10. The Compliance Team

11. The Team • An effective compliance program includes: • Compliance Officer • Compliance Committee and YOU

12. Physician Order / Documentation Begins Registration Service Areas Case Management Employee Roles Charge Description Master Health Information Management Billing Ends Collections

13. Physician Order/ Documentation Why were tests ordered? How were results used? Areas of Importance Required Elements Complaint Present Illness Systems Review Past History Diagnosis Admission Discharge Summary Signed Orders Tests & Results Appropriate Diagnosis

14. Authorization/Release Consent Forms ABN Orders LMRP/NCD Registration MSP Questionnaire 72 hour rule HIPAA Patient Demographic Information Insurance Information Pre-certifications

15. Complete/legible/signatures Proper procedure selection for billing entry system Patient Service Areas Authorization --- Orders Service = Order Documentation = Actual Services Late entries and corrections ABN Support for Medical Necessity LMRP Confidentiality

16. Charge Description Master CDM Accurate CPT Assignment Accurate Revenue Code Assignment Documentation Bundling / Unbundling Understanding HIM coding responsibility

17. Health Information Management Documentation Coding of Diagnoses / Procedures Complications/Co-morbidities Physician Queries

18. Billing Documentation Modifiers CCI Edits 72 Hour Rule Site of Service Continued…

19. Continued… Billing Documentation Modifiers CCI Edits 72 Hour Rule Site of Service

20. Collections Refunds Documentation Timeliness Documentation of Credit Balances Credit Balance Reporting Credit Balances Returned Reasonable Efforts to Collect – Medicare Bad Debts

21. Your responsibilities

22. Summary • Compliance is a Team Effort! • Personal protection • Organizational protection • Individuals can be held responsible for issues of fraud and abuse.

23. Learning Outcomes • Define corporate compliance. • Explain why we have corporate compliance. • Recognize who sets the rules that hospitals must follow. • Discuss how fraud and abuse takes place in the healthcare industry.

24. References • http://www.cms.hhs.gov/quality/mds20/MDSAllForms.pdf • http://oig.hhs.gov/reports-and-publications/workplan/index.asp • http://oig.hhs.gov/fraud/docs/complianceguidance/012705hospsupplementalguidance.pdf • http://oig.hhs.gov/authorities/docs/cpgnf.pdf • https://www.cahabagba.com/ • www.oig.hhs.gov • www.cms.gov • www.hhs.gov • www.hhs.gov/ocr/hipaa If you have any questions or concerns regarding this course, please contact Cindy Dupree at cdupree@draffin-tucker.com.