Developing A Coding, Billing & Reimbursement Compliance Program

Planning Notes

Developing A Coding, Billing & Reimbursement Compliance Program

Title: Developing A Coding, Billing & Reimbursement Compliance Program

Objective: To provide in-depth information, guidance and discussion on the systematic development of a compliance program focused specifically on the documentation, coding, billing and reimbursement process for hospitals and associated health care providers. Development the documentation and infrastructure for such a program will be provided. Special payment system concerns such as DRGs and APCs will be addressed, special service provider concerns such as for medical clinics and home health agencies will be discussed. The methodology concerning periodic audits, baseline audits and a systematic training program will be discussed. Also, the interface to the Corporate Compliance Program as well as current OIG activities will be included.

Upon Completion the Participants Will:

1. Understand the broad spectrum of compliance areas to which hospitals, systems, physicians and clinics are subjected.

2. Appreciate the severity of current compliance issues, the auditing process, demand letters, safe harbors, and the associated penalties.

3. Understand the process for developing a compliance program and process relative to the documentation, coding, billing and reimbursement process.

4. Understand the use of the systems approach in analyzing situations, discovering problems, performing research and resolving problems.

5. Appreciate the auditing and review process for conducting coding and billing audits including sample size determination and selection of random samplings.

6. Appreciate the need for and content areas for developing a ‘Billing Compliance Manual’.

5. Understand the process of developing a ‘Coding Policies & Procedures’ Manual to address the many ongoing and developing coding issues for both hospital and physician services.

6. Have knowledge of various information resources relative to the coding, billing and reimbursement process.

7. Have knowledge of the development of special compliance plans for areas such as home health, skilled nursing, durable medical equipment, and medical clinics.

8. Have reviewed the challenges of utilizing NPPs (Non-Physician Providers) relative to coding, billing and reimbursement compliance.

9. Understand how the Coding, Billing & Reimbursement Compliance Program interfaces to the Corporate Compliance Program.

10. Review the various compliance areas that are currently active and those that may become active.

11. Appreciate the special compliance concerns associated with different payment systems including DRGs and APCs.

12. Appreciate the need for a systematic, organizational approach to analyze, assess and take action in areas related to coding, billing and reimbursement.

13. Know how to utilize consultants and when to seek legal counsel and request legal opinions.

14. Appreciate the need to develop explicit information flows for both administrative and service areas.

15. Understand the role of other activities as it relates to compliance issues such as Charge Masters, Fee Schedules, Cost Reports and associated areas.

16. Appreciate the concept of a 'Baseline Compliance Audit' and the steps to begin the process.

17. Understand how the HIPAA code sets and transaction standards affect the development of a coding, billing and reimbursement program.

18. Understand how to set up a compliance training program throughout the organization.

19. Sources for further information.

Audience: All personnel involved in health care compliance and all personnel involved in the documentation, coding, billing and reimbursement process. This includes coding staff, billing staff, service area support staff, charge master coordinators, reimbursement specialists, nursing supervisors, physicians, nurses as appropriate, insurance experts, cost accountants and administrative staff as appropriate.

Method of Presentation: The primary method is Lecture Recitation with the use of case studies. Interaction and questions from the audience are HIGHLY encouraged.

Course Materials: Extensive Class Notes (including copies of Overhead Transparencies). Class Notes will include copies of selected readings and special materials as appropriate.

Student Materials: No student materials are required. Concerns about various compliance areas should be brought to class.

Prerequisites: A general knowledge of health care compliance and the current activities of the OIG, DOJ, FBI and related federal agencies.

Course Times: This is a two-day workshop – 9:00 a.m. to 4:00 p.m. for each day. Variable hours can be accommodated such as 1st Day – 10:00 a.m. – 5:00 p.m. and 2nd Day – 8:00 a.m. to 3:00 p.m.

Outline:

I. Introduction

  1. Compliance Overview
  2. Importance Of Meeting Compliance Rules & Regulations
  3. Special Health Care Compliance – OIG Model Plans
  4. General Business Compliance
  5. Systematic Approach To Maintaining Compliance
  6. Review of HIPAA, BBA 97 and BBRA 99

II. Fraudulent Practices – Coding, Billing & Reimbursement

A. Covered Versus Non-Covered Services

B. Non-Billable Services

C. Not Medically Necessary Services

D. Bundling Versus Unbundling

E. Upcoding

F. Misrepresenting

G. Mischarging

H. Misclassification

I. Other

III. Review Of OIG Model Compliance

  1. Seven Key Areas For Compliance
  2. Hospital
  3. Home Health
  4. Clinic
  5. Laboratory
  6. Skilled Nursing
  7. Durable Medical Equipment

IV. Developing A Coding, Billing & Reimbursement Compliance Program

A. Organizational Structure Development

B. Billing Policy Manual Development

C. Coding Policies & Procedures Manual

D. Systematic Problem Solving Techniques

E. Training Considerations

F. Audit & Review Considerations

G. CBR Baseline Compliance Audits

H. Settlement Agreement Implementation

  1. Provider Based Status
  1. Review Of Rules and Regulations
  2. Provider-Based Entity
  3. Provider-Based Status
  4. Department of a Hospital
  5. Qualifying and Reporting Requirements
  6. Case Examples

VI. Compliance Areas Review

  1. Payment System Interfaces
  2. Medical Necessity
  3. Coding and Modifiers
  4. DRGs
  5. APCs
  6. Charge Master/Cost Reports

VII. Compliance Service Areas Review

  1. Service Areas
  2. Home Health
  3. Skilled Nursing
  4. Rehabilitation
  5. Outpatient/Inpatient
  6. Subacute/Postacute
  7. Medical Clinics
  8. Special Programs

IX. Conducting A Baseline Compliance Audit

  1. Planning The Effort
  2. Goals and Objectives
  3. Top-Down Approach
  4. Bottom-Up Approach
  5. Quantitative versus Qualitative Methods
  6. Monitoring Over Time

X. Additional Topics

  1. Use Of Computer Technology
  2. Interfacing To Corporate Compliance Program
  3. Addressing New Payment Systems
  4. Preparing For Audits & Investigations
  5. HCFA’s Correct Coding Initiative
  6. Changes To Coding Systems
  7. Documentation Guidelines
  8. Developing A Knowledge Base
  9. Using the Internet To Access Information
  10. Sources For National Information
  11. Use Of Consultants and Legal Counsel
  12. Special Problem Areas

Notes:

  1. This is an intensive two-day workshop emphasizing practical applications.
  2. Questions submitted prior to the class are encouraged!
  3. Reference materials will be made available to class participants as a part of their notes.

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Abbey & Abbey, Consultants, Inc.