ComplianceWeek Three – Compliance Risk Reduction
Every day, a supplier faces a certain amount of “risk” in operating his or her business. To help reduce this risk, here are several areas were risk could occur. Review these areas to ensure your organization is minimizing the risk when billing Medicare. It is recommended that you randomly pull 10-15% of your charts for this review.
Corresponding Standards
ORG 5 – Compliance ProgramBC 1 – Accurate and Complete Billing RecordsBC 2 – Client Charges and Collection of Payments
PS 2 – Physician Orders and Coordination of CarePS 3 – Plan of ServicePS 6 – Client Medical Record
Failure to monitor medical necessity on an on-going basis: / ORG 5
Look at the prescription in the patient chart to see if the prescription matches the length of time the patient needed the equipment. / PS 2
PS 3
∗This is similar to continuing to bill for rental items after they are no longer medically necessary. If a physician writes a prescription for 12 months, but the patient is no longer using the equipment after 4 months, Medicare has no obligation to pay for equipment if the patient is not using it.
Failing to maintain medical necessity documentation: / ORG 5
PS 6
Audit charts for complete information that will support the claim. CMS is paying more attention to the “letter of the law” and tends to reject claims for details they let through in the past. Not having supporting documentation is the fast-track to ending up in pre-payment review. / PS 2
PS 6
∗If it’s not documented, it didn’t happen. At a minimum, the patient’s file should contain a prescription, proof of delivery, assignment of benefits, and a copy of the ABN (when applicable).
Routine waiver of deductibles and coinsurance: / BC 2
Look at 30 charts to determine if the coinsurance was properly processed. / BC 1
∗The key word is “routine;” therefore, if the supplier occasionally writes off coinsurance and deductibles there is no routine pattern established. If patterns of write-offs for a particular doctor’s patients are apparent, or if write-offs have become standard practice in the organization, these practices can be viewed as providing something of value in exchange for more referrals and then translated into a type of kickback. If the practice of writing off coinsurance is advertised to referral sources, the practice would be considered an inducement for referrals.
Failing to refund overpayments:
To a federally funded health care program: / ORG 5
Obtain a list from Accounts Payable or Finance of the thirty most recent refunds to Medicare or Medicaid. Pull the patient chart and system notes to determine when the refund was discovered and how long it took for the refund to be processed. Refunds must be paid within 60 days of discovery. / BC 1
BC 2
∗A refund policy should be written and trained annually. This policy should state that refunds to federally funded healthcare programs would be promptly refunded within a reasonable time. Refunding should occur within 60 days of discovery.
To patients/clients: / ORG 5
Obtain a list from Accounts Payable or Finance of the thirty most recent refunds to patient/clients. Pull the patient chart and system notes to determine when the refund was discovered and how long it took for the refund to be processed. / BC 1
BC 2
∗A policy should specifically state that refunds to patients are to be refunded within 60 days. The timeframe should be no different than any refunds going back to the government.
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