DEPARTMENT: Ethics and Compliance / POLICY DESCRIPTION: Reportable Events
PAGE: 1 of 3 / REPLACES POLICY DATED: 1/1/02,
RETIRED 1/24/09
EFFECTIVE DATE: January 1, 2004 / REFERENCE NUMBER: EC.020
SCOPE: All Company-affiliated facilities including, but not limited to, hospitals, ambulatory surgery centers, home health agencies, physician practices, patient account service centers, and all Corporate departments.
PURPOSE: To establish a process for identifying potential Reportable Events as defined in the Company’s Corporate Integrity Agreement (CIA) and reporting actual Reportable Events to the appropriate legal and Federal health care program authorities.
POLICY: The Company will report all Reportable Events related to compliance with laws and regulations pertaining to participation in Federal healthcare programs. Additional guidance is provided in the Correction of Errors Related to Government Reimbursement Policy, EC.012, and the Confirming and Processing Overpayments Policy, REGS.BILL.005.
Definition
“Reportable Event” means any situation that involves:
· A substantial overpayment (an occurrence or series of occurrences resulting in an overpayment of $100,000 or more); or
· A matter that a reasonable person would consider a potential violation of any criminal, civil, or administrative statute or regulation applicable to any Federal health care program for which criminal penalties, civil monetary penalties, or exclusion may be authorized. This includes, but is not limited to, violations of Stark regulations, the Emergency Medical Treatment and Active Labor Act (EMTALA), the Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), and the Anti-Kickback Act.
A Reportable Event may be the result of an isolated event or a series of occurrences.
PROCEDURE:
1. Within three business days of discovering a potential Reportable Event, or as soon as possible thereafter, the following information must be gathered, unless an exception has been granted by the Corporate Ethics and Compliance Department:
a. A complete description of the relevant facts, persons involved and legal and Federal health care program programs implicated;
b. A complete description of actions taken to correct the potential Reportable Event; and
c. A complete description of any further action planned to address the potential Reportable Event and steps to prevent it from recurring.
2. If the potential Reportable Event is a substantial overpayment, the following actions must be taken:
a. Obtain payer’s name, address, and contact person to whom the overpayment was sent;
b. For Medicare overpayments identified through HCA’s Ethics and Compliance Program and/or the processes required under the CIA (including internal and Independent Review Organization (IRO) audits, Ethics Line cases, or other corporate-level monitoring or review), complete an Overpayment Refund Form, which is Appendix B of the CIA and attached hereto as Attachment A;
c. Notify the AVP, Corporate Integrity, or the Director, CIA Implementation, within three (3) business days of discovery of a potential Reportable Event unless an exception has been granted by the Corporate Ethics and Compliance Department and follow up with a written report including a completed Overpayment Refund Form; and
d. If the potential Reportable Event is determined to be reportable, the Director, CIA Implementation, will file a CIA Reportable Event with the Office of the Inspector General (OIG), U.S. Department of Health and Human Services.
3. If the Potential Reportable Event (PRE) is a violation of the HIPAA Privacy Standards, the following procedures apply:
a. Potential violations of the HIPAA Privacy Standards must be reported after the Facility Privacy Official (FPO) or the Ethics and Compliance Officer (ECO) has done sufficient investigation and has sufficient documentation/information to support a reasonable belief that a violation has occurred.
b. Within three (3) business days of discovery of a potential HIPAA Privacy Standards violation, unless an exception has been granted by the Corporate Ethics and Compliance Department, the FPO or ECO must obtain a complete description of the relevant facts, which are to include the persons involved, and complete the CIA–Potential Reportable Event-HIPAA form. The form is located at the Ethics and Compliance website on Atlas under CIA Tools, HIPAA Reportable Events Tools, at the following link: http://atlas2.medcity.net/content/ethics/CIA_Corporate_Integrity_Agmt/CIA_%2520Implementation%2520Tools/HIPAA_Privacy_Reportable_Event/HIPAAPotentialReportableEventsFormrevised051804.xls.
c. The completed HIPAA PRE form should be forwarded by the FPO or ECO to the e-mail box address located in Outlook titled: HIPAA Privacy PREs.
d. All HIPAA Privacy Standards PREs received will be reviewed by the Ethics and Compliance HIPAA Reportable Events Manager for determination of the status of the PRE as a Reportable Event.
The ECO or FPO will be notified by the HIPAA Reportable Events Manager, via return e-mail of the form, indicating the status of the HIPAA PRE and any additional action that may be required.
e. If the potential violations of HIPAA Privacy Standards are determined to be Reportable Events, the appropriate report will be filed with the OIG.
4. If the potential Reportable Event is NOT a substantial overpayment (e.g., it may be a potential violation of law) nor a violation of the HIPAA Privacy Standards, the following steps must be taken:
a. Notify the appropriate Operations Counsel within three (3) business days of discovery unless an exception has been granted by the Corporate Ethics and Compliance Department;
b. Operations Counsel will review and determine if the situation is a possible Reportable Event;
c. If a potential Reportable Event is identified as a Reportable Event, Operations Counsel will provide a completed CIA Potential Reportable Event Form to the Director, CIA Implementation;
d. The Legal and the Ethics & Compliance Departments will determine if the possible Reportable Event is an actual Reportable Event; and
e. If such determination is made, the Director, CIA Implementation, will file the Reportable Event with the OIG.
The Chief Executive Officer or Administrator and the Ethics and Compliance Officer of each Company-affiliated facility are responsible for the implementation of this policy.
REFERENCES:
Corporate Integrity Agreement, effective January 2001
Correction of Errors Related to Government Reimbursement Policy, EC.012
Confirming and Processing Overpayments Policy, REGS.BILL.005
3/2006
OVERPAYMENT REFUND
TO BE COMPLETED BY MEDICARE CONTRACTOR
Date: ______
Contractor Deposit Control #: ______Date of Deposit: ______
Contractor Contract Name: ______Phone #: ______
Contractor Address: ______
Contractor Fax #: ______
TO BE COMPLETED BY PROVIDER/PHYSICIAN/SUPPLIER
Please complete and forward to Medicare Contractor. This form, or a similar document containing the following information, should accompany every voluntary refund so that receipt of check is properly recorded and applied.
PROVIDER/PHYSICIAN/SUPPLIER NAME: ______
ADDRESS: ______
PROVIDER/PHYSICIAN/SUPPLIER #: ______CHECK #: ______
CONTACT PERSON: ______PHONE #: ______
AMOUNT OF CHECK: $______CHECK DATE: ______
REFUND INFORMATION
For each Claim, provide the following:
Patient Name: ______HIC #: ______
Medicare Claim Number: ______Claim Amount Refunded: $______
Reason Code for Claim Adjustment: ______(Select reason code from list below. Use one reason per claim)
(Please list all claim numbers involved. Attach separate sheet, if necessary)
Note: If Specific Patient/HIC/Claim # / Claim Amount data is not available for all claims due to Statistical Sampling, please indicate methodology and formula used to determine amount and reason for overpayment: ______
______
______
For Institutional Facilities Only:
Cost Report Year(s): ______
(If multiple cost report years are involved, provide a breakdown by amount and corresponding cost report year.)
For OIG Reporting Requirements:
Do you have a Corporate Integrity Agreement with OIG? ______Yes ______No
Reason Codes:Billing/Clerical Error / MSP/Other Payer Involvement / Miscellaneous
01 – Corrected Date of Service / 08 – MSP Group Health Plan Insurance / 13 – Insufficient Documentation
02 – Duplicate / 09 – MSP No Fault Insurance / 14 – Patient Enrolled in an HMO
03 – Corrected CPT Code / 10 – MSP Liability Insurance / 15- Services Not Rendered
04 – Not Our Patient(s) / 11 – MSP, Working Comp. (Including Black Lung) / 16 – Medical Necessity
05 – Modifier Added/Removed / 12 – Veterans Administration / 17 – Other (Please Specify)
06 – Billed in Error / ______
07 – Corrected CPT Code
Corporate Integrity Agreement Attachment to EC.020
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