Portfolio Project (Compliance Program for North Side Medical Corporation)

COMPLIANCE PROGRAM1

Portfolio Project (Compliance Program for North Side Medical Corporation)

Frank Skwierc

Bryant & Stratton College

MRC 145 Coding Compliance & Ethics Systems

Ms. Jorell Lawrence

February, 27, 2016

ABSTRACT

This assignment was designed by Ms. Lawrence, to demonstrate that we have a complete understanding of a compliance program and ethics. The objective of the assignment is to create a medical practice compliance plan based on national standards, and have a thorough understanding of coding, documentation, and reimbursement ethics. The scenario of this project is that I have been hired to create a new compliance program for the fictitious company named North Side Medical Corporation. Key points for introduction and body paragraphs that need to be addressed are:

• An overview of the professional fee billing program.
• Describe the plan and any additional background information.
• Choose a billing company. And justify the reason for the company.
• Designate an official responsible for directing the effort to enhance the compliance program, including implementation of the plan. And justify the reasoning for the designation.
• Incorporation of standards and policies that guide Northside medical Corporation personnel with regard to professional the billing.
• Development of compliance initiatives at all applicable levels.
• Creation of a uniform mechanism for employees to raise questions and receive appropriate guidance concerning professional fee billing.
• Development of a process for employees to report instances of possible noncompliance and for such reports to be fully and objectively review
• Implementation of a system or schedule by which Northside reviews regularly its charts and billing.

This will also include a concluding paragraph that summarizes the compliance program and reiterates the important points. The length of the plan should be a minimum of 2500 words or five pages not including title pages and reference pages.

INTRODUCTION

Healthcare compliance is a major concern of every medical organization. This is especially true when it comes to the organization’s billing practices. To eliminate cloned electronic health records and poor physician documentation and to follow the laws and guidelines that pertain to Emergency Medical Treatment and Active Labor Act (EMTALA) and Stark Law and Anti-kickback Statutes, all organizations must be compliant with the changing healthcare trends, guidelines, laws, and government regulations to minimize the risk. To minimize liability risks and avoid government scrutiny the organization can benefit from a medical compliance plan and the services of a healthcare compliance officer. This is the best way to ensure your claims and processes are clean and compliant with government and third party reimbursement requirements(Aapc.com, 2016).

Medical organizations, need to hire or appoint someone who can develop, organize, manage, and direct the functions of the compliance program. A certified professional compliance officer is trained to handle all these situations. The compliance officer will be able to maintain your compliance program, and ensure that your staff receives the training and guidance they need. These individuals are very familiar with Stark law, Health Insurance Portability and Accountability Act, Governmental investigative audit programs, and handling internal investigations that result from internal audits(Aapc.com, 2016).

Your organization, will also need to select a billing company that is up to date, that can provide you with the necessary documents that your physicians and coding staff will need for reporting medical necessity, and ensure proper coding of procedures and diagnoses, that meet compliance by government standard. There are many companies out there that can provide you with the tools you need, however, for your needs I recommend. XeroxHIMSS16, this company can help you implement EHR and ERP, optimize business processes, increase technology adoption, deliver quality and care data, support claims accuracy, communicate member benefits, drive medication adherence, provide risk assessments, and enable access for patients(Xerox, 2015).

Healthcare Compliance Program

North Side Medical Corporation

Introduction

North Side Medical Corporation(NSMC), is committed to full compliance with the billing practices of (NSMC) and with all applicable laws and regulations, as outlined by the Office of the Inspector General, and the US Department of Health and Human Services. It is the obligation of all personnel working for (NSMC) to adhere to the compliance program and maintain ethical standards. The purpose of this compliance program is to detect and prevent any violations of State, Federal, and Local Laws, as well as, company policy involving the operation or the billing practices of North Side Medical Corporation and to ensure that all employees, that work for, or affiliated with (NSMC) understand that anyone found to be in non-compliance will be dealt with severely(Office of Inspector General, 2016).

Company Policy on Ethical Practices

North Side Medical Corporation (NSMC), has developed policy and procedures that describe how the duties and obligations of personnel are to be performed to maintain its high level of ethical standards, and to adhere to the compliance program. Failure to maintain and comply with the requirements of this compliance program, or with company policy, will be viewed seriously, and individuals found to be in noncompliance will be subject to disciplinary action, up to and including legal actions taken against them. To ensure that all personnel working for (NSMC) adhere to Company Policy and its Ethical Practices they will betrained on the Company’s Code of Conduct. The Compliance Program details the fundamental principles, values, and guidelines for compliance within the organization. The Compliance Program will instruct you on acceptable behavior by making clear the expectations we expect from our personnel on complying with all company policies and applicable government laws, rules and regulations. It is imperative that all personnel follow these guidelines and that they understand that it is their duty to report violations of the law or company policy to appropriate supervisors(Aapc.com, 2016).

North Side Medical Corporation/Compliance Program

North Side Medical Corporation is dedicated to having an effective compliance program that includes the following elements:

1. Designation of a chief compliance officer and a compliance committee.
2. Development of a written compliance policies and procedures which contain written standards of conduct.
3. Establishes open lines for communications or reporting noncompliance that permits anonymous reports can be made without fear of retaliation.
4. That has an appropriate training and education program.
5. An internal monitoring and auditing system.
6. Outlines enforcement and disciplinary standards.

The compliance program reviews and evaluates compliance issues and concerns within the organization as they relate to federal state and health care programs, and is designed to ensure compliance with all laws and regulations relating to those programs (Office of Inspector General, 2016).

Appointing a Chief Compliance Officer and a Compliance Committee.

To ensure that the (NSMC)’s Compliance Program is implemented and maintained properly according to the guidelines set up by the Office of the Inspector General. A Certified Professional Compliance Officer, (CPCO), will be appointed to oversee the Compliance Program. The individual selected will be based on their honesty, integrity, and high ethical standards. They will possess a Bachelor’s degree or Master’s degree and have a minimum of 10 years’ experience in the healthcare field and be able to demonstrate leadership ability. This officer will be required to effectively develop, implement and monitor the health care compliance program. This includes being knowledgeable of governmental regulatory guidelines, how to conduct audits, and educate and train personnel working for (NSMC). The duties and responsibilities of the Chief Compliance Officer shall include, but is not limited to, the following:

1)Develop, maintain, initiate, and revise policy and procedures for the compliance program and its related activities to prevent illegal, unethical, or improper conduct on a day to day basis.

2)Periodically review and update standards of conduct to ensure continued compliance of management and staff personnel.

3)Collaborate with other departments within the organization about compliance issues and to take appropriate actions in terms of investigation and resolution.

4)To respond to any allegations of violations of rules, regulations, policies, or procedures. And develop and oversee a system designed to handle such violations.

5)Identify potential areas of vulnerability in the compliance program and develop and implement a plan of action to resolve these issues.

6)Reports on a regular basis, or as directed or requested, to the CEO and the board of trustees, informing them of operational issues and the effectiveness of the compliance program.

7)Reports violations or potential violations to enforcement agencies as required by taking appropriate action.

8)Works with the human resource department and other departments within the organization to develop a compliance training program for new employees, plus an ongoing training program for all personnel.

9)Sets up a system for individuals to report noncompliance by other individuals within the company or agencies affiliated with the company. This should include an employee Hotline, written, or email, that individuals can use for this purpose without fear of retaliation.

10)Keeps a constant monitor on the performance of the Compliance Program and continues to take appropriate steps to improve the Compliance Program.

11)Selects appropriate qualified staff members from each department for a committee to help implement and maintain the Compliance Program and develop an effective training program for all personnel (Aapc.com, 2016).

Written Compliance Program Policies and Procedures

When claiming payment for services rendered by (NSMC) there are numerous compliance policies and procedures that all employees regardless of rank or tenure must abide to, so that the Corporation can maintain the integrity and industry standards of the Corporation. Billing will be done in compliance with all applicable State and Federal Laws and Regulations. No bill will be issued for a clinical service unless it was actually performed and documented. Each department will be responsible to develop its own billing compliance procedures. These procedures will be subject to approval by the Chief Compliance Officer. (NSMC) has an obligation to its patients, third-party payers, and the state and federal government to exercise due diligence, care and integrity to ensure the accuracy of every claim that is submitted. False billing is a very serious offense and will not be tolerated. Medicare and Medicaid laws prohibit knowingly and willfully submitting any false information, or statement, when submitting a claim for benefits or payment. It is also unlawful to conceal, or fail to disclose, an event affecting the right to a payment with the intent to secure a payment that is not due. Examples of false claims include:

• Claiming reimbursement for services that were not rendered.
• Filing duplicate claims.
• “Up coding” to a more complex procedure than the actual procedure that was performed.
• Falsely indicating that a particular healthcare professional was present for a procedure, or that services were rendered when they were not.
• Providing billing for a length of stay beyond what is medically necessary.
• Billing for services or procedures that are not medically necessary.
• Failing to provide documentation proving medical necessity or services.
• Billing for excessive charges, that exceed the normal standards set by the government for Medicaid and Medicare services.
• Failing to report a billing error that constitutes an overpayment from the government or third-party insurance carrier.

Healthcare fraud or false statements relating to health care matters that attempt to defraud any health care benefit program by means of false, fictitious, or fraudulent pretenses, in an attempt to ascertain money or property will result in disciplinary actions up to and including legal action taken against them. Failure to report an instance of fraud or noncompliance is a violation of the company’s Compliance Program and individuals will be dealt with severe disciplinary action (Office of Inspector General, 2016).

Establishing Open Lines for Communication

The (NSMC), encourages all employees to report violations concerning any wrongdoing in documentation, coding, billing services, equipment use, or the use and removal of supplies. Especially those involving any violation of any law, regulation, or facility policy associated with (NSMC). Employees are required to report these violations promptly so that (NSMC), so that an investigation can be conducted an appropriate action be taken. Any employee failing to report suspected violations may be subject to disciplinary action, up to and including termination. We are aware that some individuals may be reluctant to discuss wrongdoing with their supervisors because they fear of retaliation. Here at (NSMC), we guarantee that no retaliation will be taken on any personnel who come forward with concerns of violations and are making them in good faith. Below is a list on the proper procedures and individual can take for reporting known violations:

1. Any personnel that are aware of suspected illegal or on ethical conduct or a violation of (NSMC) policy, should immediately report it in verbal or written form to the appropriate individual in charge. This may include the immediate supervisor, department manager, company compliance officer, human resource officer, or CEO.
2. Personnel also may take advantage of our toll-free compliance hotline, or our web Internet service. Reports using these methods may be made anonymously if the individual chooses to do so.
3. North Side Medical Corporation, understands that individuals may commit violations of the law, company policy, and company compliance, and not realize their mistake until a later date. Should this occur we encourage self-reporting, and individuals who take advantage of this will be given due consideration and potential mitigation of any disciplinary action that may have been taken.
4. Once the report is received an investigation into the allegations made will be done to determine the validity of the allegation. If the allegation proves to be true, appropriate actions will be taken to correct the problem or violation and to administer any disciplinary action necessary. However, should allegations prove to be false, maliciously, or frivolously, in an effort to discredit another employee, appropriate disciplinary action will be taken against the person making the accusation, up to, and including termination.
5. Any supervisors or employees that take part in retaliation for reprisal against anyone reporting violations in good faith, or impede an investigation, is strictly prohibited by law, and is also a violation of (NSMC)’s code of conduct and company policy.
6. Any individual of (NSMC) who exposes wasteful, harmful, or illegal acts, known as a Qui Tam reporter, is protected by the FCA from termination, demotion, suspension, or discrimination related to these claims. The individual reporting these incidents of fraud are often rewarded for their efforts (Safian, 2009).

Training and Education Programs

North Side Medical Corporation provides training to all entry-level personnel and current personnel on all compliance laws and regulations, as well as, though rules that apply to (NSMC)’s code of conduct and company policy. These training and educational programs are in the form of classroom studies and seminars. Training programs such as these are required by new and ongoing personnel and may be as part of a retraining program for disciplinary action. These training programs are designed to accomplish the following:

1. To ensure that all of (NSMC)’s personnel know and understand all the elements of the compliance program.
2. That personnel have a complete understanding of all the applicable laws, policies, and procedures set forth by government standards and are aware of where these laws, policies, and procedures can be found for review.
3. These classes will also address the ethical standards and compliance expectations that (NSMC) expects from its employees.

The purpose of these training programs is to ensure that all personnel and other individuals working on behalf of (NSMC) are capable of performing their jobs to ethical standards and within compliance, of all the rules, regulations, and other standards set forth by the government and (NSMC) (Cannoy, 2010).

Internal Monitoring and Auditing System

North Side Medical Corporation personnel are required to participate and cooperate in all internal auditing and monitoring activities. It is the duty of the Compliance Officer to develop an annual audit plan. The plan must include compliance committee officers, department heads, and supervisors that will help conduct and oversee these audits. The plan should be designed to detect and monitor any misconduct or violations in compliance and billing. These internal audits should be performed annually, or as often as needed, to address and identify any significant compliance issues. The results of audits will be reviewed by compliance committee officers, department heads, and supervisors. Should any issues of noncompliance be detected it is their job to take appropriate action to correct these issues (Safian, 2009).

Enforcement and Disciplinary Standards

Should any personnel working for North Side Medical Corporation be found violating any law, or regulation as outlined by the AHIMA, or the code of conduct, company policy, or the company’s compliance program, will be subject to the appropriate disciplinary action. This action also includes, individuals who fail to report noncompliance. The level of disciplinary action taken will be taken will be appropriate with the severity of the noncompliance reported. Disciplinary action can be, up to and include termination. Types of disciplinary action that may be taken are as follows:

1. Written warning will befor minor violations and first-time violations. This document must outline the type of violation and be placed in the personnel file. Things that should be included in this written warning are:

a)The time and date of when the warning was given.

b)The suggestions made to the employee.

c)The employee’s response.

1. Informal disciplinary action. This form of action will be takenon individuals that (NSMC) believe whose behavior is correctable. This action willconsist of the employee to either attend a seminar or go through a retraining program. This form of discipline should include the following:

a)The date and time of the issuance of the additional education required.