PAGE:1 of 5 / REPLACES POLICY DATED: 1/1/2001, 2/8/2001. 5/1/2002, 9/1/2002, 5/15/2003
EFFECTIVE DATE: January 1, 2004 / REFERENCE NUMBER: GOS.GEN.007
SCOPE: All Company-affiliated facility and corporate personnel who work more than 160 hours per calendar year and the applicable Covered Contractors (who work more than 80 hours per calendar year), involved in the performance of billing and/or billing-related services (e.g., reviewing, editing, coding and/or filing of the final bill) for Federal healthcare programs at Company-affiliated facilities and Corporate Departments, Groups and Divisions, including but not limited to:
Business Office Director/Billing Director Billing Helpline Personnel
Laboratory Director AmbulatorySurgeryCenter PersonnelOutpatient Coders Corporate Health Information Management Services
Facility Health Information Management Billers
Physicians Employed Directly by the Hospital Covered Contractors
PURPOSE: To ensure that all personnel involved in billing and/or billing-related services for Federal healthcare programs are aware of billing guidelines and regulatory changes, which may impact complete, accurate and consistent billing. The purpose of training shall include the following: (a) the submission of accurate bills for services rendered to Federal healthcare program beneficiaries; (b) policies, procedures and other requirements applicable to the documentation of medical records; (c) the personal obligation of each individual involved in the billing process to ensure that such billings are accurate; (d) applicable reimbursement statutes, regulations, and program requirements and directives; (e) the legal sanctions for improper billings; and (f) examples of proper and improper billing practices.POLICY:
- Each person involved in the performance of billing and/or billing-related services for Federal healthcare programs as well as the Business Office Director and the Laboratory Director must complete a minimum of eight (8) education hours per calendar year in billing and/or billing-related services. Only Company-designated programs may count towards this requirement.
- Newly hired personnel involved in the performance of billing and/or billing-related services for Federal healthcare programs must complete a minimum of eight (8) education hours within the first 90 days of employment.
- In any situation where training requirements have not been completed, a fully-trained HCA employee shall carefully monitor the work of the untrained person.
- This policy does not replace other policies that address continuing education requirements specific to functional areas (such as the Coding Continuing Education Requirements Policy, HIM.COD.006, and the Coding Continuing Education Requirements for Company-Owned Professional Services Policy, HIM.PHY.006).
Federal healthcare program: Any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government (other than the health insurance program under chapter 89 of title 5 of the United States Code — the Federal Employees Health Benefit Program); or any State health care program, as defined in 42 U.S.C 1320a-7(h).
Federal healthcare programs include, at a minimum, the following:
- Medicare Program, Parts A & B (Title XVIII of the Social Security Act); (but not Medicare managed care plans)
- Medicaid (Title XIX of the Social Security Act); (but not Medicaid managed care plans)
- Federal Prison Hospitals (prisoners);
- Indian Health Service;
- OWCP (workers' compensation for federal employees);
- Public Health Service;
- Railroad Retirement Board;
- The Black Lung Program;
- TRICARE/CHAMPUS/Department of Defense healthcare programs (Chapter 55 of Title 10, United States Code); and
- Veterans Administration (VA).
CIA: Corporate Integrity Agreement, effective January 2001
Covered Contractor: A Covered Contractor is any agent or other individual (who is not a covered person) who prepares claims, cost reports, or other requests for reimbursement from any Federal health care program on behalf of HCA or any of its subsidiaries on a regular basis (i.e., for more than 80 hours within the calendar year).Biller: A biller (inpatient or outpatient) is an individual who prepares, reviews, updates and/or submits claims to third party payers for reimbursement of medical services provided. The billing function includes the verification and correction of billing data for accuracy and completeness following regulatory requirements prior to claim submission. This function also includes resolving edits or exceptions detected during system processing of the claim. These claims may be submitted on a CMS 1450 (UB-92) or on a CMS 1500.
The definition of biller also includes any employee’s immediate supervisor who supervises the preparation, review, updating and/or submission of claims to a third party payer for reimbursement of medical services provided.
(Only billers who bill Federal healthcare programs must be tracked in the Company’s Learning Management System.)
Example:
If an employee is making changes/editing directly into EP Billing Vendors, Common Working File (CWF), Fiscal Intermediary Shared System (FISS) or Medicaid on-line systems or if the employee changes or signs a manual claim, this employee is considered a biller.
If an employee is reviewing the medical record and making recommendations to the biller and not making changes/editing directly into EP Billing Vendors, CWF, FISS or Medicaid on-line systems, this employee is not considered a biller.
Employees who only make changes to the CDM or only enter charges through Meditech are not considered billers.
Billing Training: Billing Training is defined as the training requirements defined in the Continuing Education Requirements Policy, GOS.GEN.007.
Business Office Director/ServiceCenter Billing Director: A Business Office Director is defined as a person who supervises individuals meeting the definition of “biller.” This designation is made based on the individual’s job function, regardless of title, i.e., this individual may or may not have the title Business Office Director.
Other Billing Personnel: Other Billing Personnel are employees who are not considered billers according to the above definition, but must meet the biller education requirements as outlined in this policy. These are employees who review the medical record, determine the appropriate use of modifiers and apply the modifier directly into the patient accounting system(s).Employees who do not enter modifiers directly into the patient accounting system(s) are not required to meet the education requirements outlined herein.
Employees entering CPT/HCPCS codes directly into the patient accounting system are considered outpatient coders. Reference Company policy HIM.COD.006 regarding the education requirements for outpatient coders.
Outpatient Coder: Refer to Company policy HIM.COD.006 for the definition of outpatient coder.
In the event that an outpatient coder (as defined in HIM.COD.006) also performs the billing function (see definition of Biller), the individual is categorized as an Outpatient Coder for purposes of reporting.
Physicians Employed Directly by the Hospital: Those physicians who are employed full-time directly by the hospital and who are involved in the ordering, performing or monitoring of laboratory tests or services or the preparation of outpatient claims containing laboratory tests or services.
Employed physicians who meet the definition of biller are required to complete the educational requirements outlined in this policy. Employed physicians who do not meet the definition of biller are required to complete the education requirements as outlined in the Company’s Laboratory Compliance Plan. The Laboratory Compliance Plan may be accessed via Atlas at:PROCEDURE:
1.The facility Ethics and Compliance Officer (ECO) or Corporate Responsible Executive must designate an appropriate person (e.g., Local System Administrator, Department Director) to track the required education hours for each person involved in billing and/or billing-related services for Federal healthcare programs.
2.It is the responsibility of the direct supervisor to ensure that each person supervised who is performing billing and/or billing-related services for Federal healthcare programs receives the required eight (8) hours of billing education per calendar year.
3.The completion of billing education hours, as defined in this policy, must be tracked using the Company’s Learning Management System (LMS).
4.The designated person will be responsible for reporting completed education hours on a quarterly basis by using the ECO Quarterly Report.
- Applicable Covered Contractors who perform the billing function must work with the facility and/or corporate office to receive applicable training.
- Any person involved in performing billing and/or billing related services for Federal healthcare programs who does not meet the designated time-frame for completion of the training must be reported to the ECO by the person’s direct supervisor. The name of the person who did not meet the designated time frame in obtaining the required hours of billing training, the name of his or her direct supervisor must be reported by the ECO to:
- the Division President, for a hospital employee; or
- the Company’s President and Chief Operating Officer, for an employee at the Corporate office; or
- an individual in a position equivalent to the Division President, for an employee in any other setting.
- The Corporate Government Programs Department will issue a certificate to each person who attends training covered by this policy that is supplied by Governmental Operations Support. The certificate will identify the number of hours applicable towards this policy’s billing education requirement.
- The facility must be able to prove compliance with this policy when requested.
REFERENCES:
Coding Orientation and Training Policy, HIM.COD.005
Coding Continuing Education Requirements Policy, HIM.COD.006
Coding Orientation and Training for Company-Owned Professional Services Policy, HIM.PHY.005
Coding Continuing Education Requirements for Company-Owned Professional Services Policy,
HIM.PHY.006
10/2003