Chief Officer: Elvin (Bud) Howland, Director Corporate Compliance

Chief Officer: Elvin (Bud) Howland, Director Corporate Compliance

969-7195

Compliance Committee: Joanne Schmidt, RN, Exec Director, CMCI; Ellen Z. Perin, Director of Finance; Lauren Layman; Debbie Bean; Judy Garrick; Margaret Polacek

COMMUNIITY MEDICAL CARE, INC.

Introduction

By order of the Office of the Inspector General (OIG), this compliance program has been written by the chief officer and the compliance committee. Each individual, who is employed by Community Medical Care, Inc, has reviewed and received a copy of our compliance program. A signed acknowledgement to this effect is contained in the employees personnel file attesting that the employees of Community Medical Care, Inc .have read and understand these policies.

COMMUNITY MEDICAL CARE, INC.

Goals of Compliance

1. To conduct business in an ethical and lawful manner

2. To educate all employees and physicians regarding federal programs

3. To clearly communicate federal regulations to patients and their responsibility to uphold them

4. To help educate our physicians and physician extenders on correct ethical coding

5. To evaluate all billing and coding practices annually at a minimum

6. To establish effective communication with employees and our physicians regarding compliance.

7. To help our physicians and physician extenders improve medical record documentation

8. To maintain an excellent working relationship with Medicare and other payers of service

COMMUNITY MEDICAL CARE, INC.

Code of Conduct

1. Community Medical Care, Inc. will not charge for services not rendered.

2. Documentation of services rendered will be complete and legible.

3. Evaluation and Management coding will adhere to established Medicare guidelines.

4. Diagnosis codes that are reported will be descriptive of the purpose for which a service was performed.

5. Modifiers will be used only when justified by the need for this service.

6. Medical necessity requirement will at all times be adhered to.

7. Community Medical Care, Inc. will validate all coding information by using reputable resources.

8. Medicare and CPT guidelines will be reviewed on an on-going basis.

9. Community Medical Care, Inc. will incorporate a commitment to compliance in all aspects of its business, including its personnel manual, criteria for hiring, evaluation tools and job descriptions.

10. CMCI will not knowingly hire individuals excluded from the Medicare or GSA Program, including physicians as well as employees. CMCI requires mandatory discharge of employees or physicians who become excluded during their employment with Community Medical Care, Inc.

COMMUNITY MEDICAL CARE, INC

Billing Policies and Procedures

The following is a list of our procedures that are followed on a daily basis by all billing employees/or front desk personnel of Community Medical Care, Inc. Central Business Office and all Practice Sites:

1. All daily work sheets are checked for accuracy against the appointment schedule to make sure that we have a charge and payment if appropriate for each patient who was scheduled. The front desk office personnel notify all patients who did not keep their appointments in follow-up.

2. Provider charges are verified in our system for accuracy as far as procedure and diagnosis code and correct modifier use. Report is generated and matched against daily work sheet for accuracy.

3. Electronic claim submission to payers is done at the end of each day for those charges that were inputted that day. Reports are run to cross check that all claims are sent. Acceptance reports (EDI) are automatically generated by our third party payers and downloaded and printed the next morning. All front-end verification reports are kept on file.

4. All primary (1500) HCFA forms are run and matched to any appropriate documentation and mailed at the end of each day following the same format as we do for electronic claims submission.

5. Any payments (EOB’s) that are received on a daily basis are batched, each check is copied and inputted and balanced against the deposit for that day.

6. All secondary bills are also generated on a daily basis; during payment posting, appropriate patient statements are also generated at this time.

7. Claims requiring a formal appeal are brought to the attention of the manager, who reviews and determines if the appeal process should take place. If appeal is processed, it is sent with all appropriate documentation (copy of coding manuals, inpatient/outpatient progress notes, discharge summaries or consultation reports etc.) is attached to the appropriate appeals form. Forms are mailed, copies are kept, and patient account is noted by placing a note on the account for follow-up in 30 days. If appeal is denied, manager is notified and makes the final decision on final disposition of account.

8. All routine claims follow up begins at day 31, carriers are called and if necessary, resubmission and or correction of claims occur. All follow-ups are properly documented in account notes within the patient’s individual account.

9. Any overpayment that occurs during payment posting creates a negative balance in the patients account. Manager is notified via refund request form to secure refund to either patient or insurance company. No insurance account is left in negative status longer than 60 days.

10. All patients who are balance billed are notified of their balances by generating three (3) patient statements. The third statement notifies the patient of our practices intent to turn their account over to our collection agency for recovery.

11. All effort is made to collect any account over 45 days; all patients are offered options to settle their account, either by making payment arrangements, credit card or by post dated check.

12. All accounts pending collection agency activity should be presented to Director of Finance through Central Business Office Manager with complete itemized bill, all account notes, and any other appropriate documentation relating to collection efforts. Director of Finance will make determination of pursuing collection efforts or the disposition of the patient account balance.

COMMUNITY MEDICAL CARE, INC.

Coding Policies

1. All Inpatient billing is reviewed and coded as appropriate from the physician billing form, progress notes, hospital consultation forms and discharge summary information. Any questions regarding the procedure codes are directed to the appropriate physician who billed the service. Physicians are exclusively responsible for choosing the level of care through the use of CPT codes. If necessary the use of a modifier is applied to let the carrier know that an additional payment is requested, or to offer a better description of the procedure.

2. Any coding problems or questions are brought to the attention of the manager for accurate coding, if the manager needs any additional clarification, the manager will bring the problem to the attention of the physician who performed the procedure/service or chose the evaluation and management code (E&M).

3. Any procedure or service that is not clearly documented will not be coded or billed without clarification from the attending physician.

4. Any trends identified by posting staff in coding errors, payment errors or denials will be brought to the attention of the Central Business Officer manager and/or Director of Finance, CMCI.

COMMUNITY MEDICAL CARE, INC.

Risk Assessment

1. Billing for items or services not actually documented, if on occasion a physician neglects to mark a service or item provided during a office or inpatient visit/procedure, the billing staff will contact the manager and will check the patient’s progress note, chart consult sheet or dictated documentation to clarify whether the service was billed appropriately, if after reading the patient’s progress note, chart consult sheet or dictated documentation the billing staff and manager are unclear as to whether the service was performed, they will contact he physician in question who reported the service.

2. Unbundling of services is not permitted; Community Medical Care, Inc. continually updates the correct coding initiative material to prevent unbundling.

3. Up coding is not permitted by billing staffs, all office procedures and or visits are chosen by the appropriate physician providing the service.

4. Inappropriate balance billing is not permitted by the billing staff, all insurance companies and patients balances are billed according to specific carrier guidelines.

5. The use of passwords and appropriate levels of security within our Medent software system maintain computer program security at Community Medical Care, Inc..

6. Confidentiality is maintained on all patient health and billing information. Each

employee of Community Medical Care, Inc. when hired sign and agree to up hold all patient information in strict confidence. Employees are informed that patient account information is not discussed with anyone but the patient.

An individual must give date of birth and social security number before any information is discussed. If the patient is a minor, the account can be discussed with the patient’s guardian. Care is always taken to identify the patient. The only exceptions to this rule include discussing the case with the payer of service in order to get the patient’s account paid and CMCI legal counsel if the claim is in litigation. All other discussions of patient’s information will require HIPAA appropriate signature to release. Failure of an employee to maintain confidentiality is grounds for immediate dismissal.

7. Duplicate billing is not permitted by any employee of Community Medical Care, Inc. Community Medical Care, Inc. adheres to all federal and state regulations for submitting medical claims. Two (2) or more carriers are never billed for the same date of service or duplicate procedures on the same date of service. The patient’s identified primary carrier is billed only once. See billing policies and procedures section for detailed billing guidelines.

8. Community Medical Care, Inc. compensates its employees at an appropriate salary determined by the employee’s level of experience and education. It does not compensate employees by any monetary incentive with the promise of increased cash flow.

9. Community Medical Care, Inc. cautions our physicians regarding giving discounts for services rendered. All physicians are aware that they could be in serious non-compliance if they waive patient’s co pays and deductible amounts as deemed by the carrier. Only patients who have signed an indigent waiver and shown proof of financial hardship are given any type of professional discount or waiver.

10. Community Medical Care, Inc. is committed to appropriate coding for all services billed by our physicians. Continuing education is a requirement of all of our billing staff. This is achieved by attendance at seminars, and/or course materials for home study or college class work.

11. Community Medical Care, Inc. keeps copies of all seminar attendance, certification, disciplinary action, performance reviews and any training materials in each employees personnel file.

12. A phone line has been established, as suggested by the OIG, in order to prevent or report fraud and abuse. This phone number is posted in the office and is available to all employees. Reports and/or complaints and any resulting investigation are acted upon if necessary, and/or reported to the appropriate authorities. All reports are kept in a confidential file in the Billing office.

13. The compliance officer/committee is responsible for the direct training or delegation of training on all compliance procedures/ all employees of Community Medical Care, Inc. are informed that strict observance of all procedures set forth in this manual are a condition of continued employment. Failure to comply results in corrective disciplinary action, which is documented in the form of a written warning and/up to immediate termination of the employee.

COMMUNITY MEDICAL CARE, INC.

Compliance Training and Education

1. All employees of Community Medical Care, Inc. are required to attend an initial overall training session reviewing our compliance plan.

2. All employees will be responsible for reporting any non-compliant activity by any of their co-workers and or activity by a provider of service directly to the Compliance Officer and committee who will investigate and proceed with a step-by-step disciplinary action.

3. Each employee of Community Medical Care, Inc. will receive a copy of the compliance plan. A signed affidavit stating that it was received, read and understood will be kept in the employee’s individual personnel file.

4. All Billing employees of Community Medical Care, Inc. are required each calendar year to complete 8-16 hours of continuing education. Education can be in the form of attendance at a seminar, an outside facility or in-house training with material purchased from educational facilities specializing in coding, billing, and general or specialized medical information.

5. New employees all begin with basic training which includes but is not limited to the following:

a). All federal and state regulations (see handout compliance manual)

b). How to read an insurance card.

c). How to use an ICD-9 and CPT reference manual.

d). Where to look for or who to go to for medical information that may be unfamiliar.

e). Intensive training on how and when to use modifiers.

f). How to read an EOB.

g). Review of E& M coding guidelines (billing staff) 1995/1997

6. All billing and training materials including any coding changes, are kept in binders within the office. This information is always available to all employees at anytime to reference if they should have any questions or concerns on why a particular code was billed.

7. Any violations, regarding coding issues are addressed by the compliance officer, any employee who willfully changes or modifies a code, or refuses to follow the practices policies and procedures regarding collections and billing are to be disciplined as follows:

a). a verbal warning with training on problem area

b). a written warning with additional training and a 30 day

probation period.

c). third offense results in termination of employment.

COMMUNITY MEDICAL CARE, INC.

Auditing and Monitoring

1. Community Medical Care, Inc. monitors and reviews elements of our compliance program. This audit is done to determine whether or not all compliance elements have been met.

2. The review process includes but is not limited to the following:

1.) Testing of billing and coding staff on knowledge of reimbursement and coverage.

2.) Yearly review of a sample of at least 5 charts per physician to verify documentation for E&M codes for both inpatient and out patient charting.

3.) Examination of complaint log.

4.) Yearly evaluation of employees and checking of personnel records for proper documentation to support level of continuing education for billing personnel.

3. The compliance office will complete all Reviews; if the compliance officer finds credible evidence of misconduct the disciplinary process will begin and be documented in the employees personnel file. If the compliance officer feels that the misconduct may violate criminal or civil law, the officer will report the misconduct promptly to the board of directors of the organization.