DEPARTMENT: Regulatory Compliance Support / POLICY DESCRIPTION: Billing Monitoring
PAGE:1 of 2 / REPLACES POLICY DATED: 1/16/98, 3/1/99, 10/1/01 (GOS.GEN.001)
EFFECTIVE DATE: March 6, 2006 / REFERENCE NUMBER: REGS.GEN.001
SCOPE: All Company-affiliated hospitals performing and/or billing services. Specifically, the following departments:
Business Office Nursing
Admitting Ancillary Services
Finance Health Information Management
Administration Utilization Management
Revenue Integrity Patient Account Services
Medicare Service Centers
PURPOSE: To establish an effective monitoring process for billing policies and procedures.
POLICY:
  1. Each facility and/or service center must establish a monitoring process for reviewing compliance with the Company's billing policies and procedures. Each billing policy and procedure should be reviewed to define the payer scope of the monitoring activity. At a minimum, monitoring should be performed for Medicare, Medicaid and other federally-funded payers.
  1. The monitoring process will consist of two types of monitoring activities:
A. Automated Monitoring
Automated monitoring of claim level data will be performed at pre-determined frequencies by the Regulatory Compliance Support department for the following laboratory billing policies:
REGS.LAB.002,Hematology Procedures
REGS.LAB.003,Urinalysis Procedures
REGS.LAB.004,Organ and Disease Panels
REGS.LAB.006,Outpatient Specimen Collection
REGS.BILL.006, Stat, Call Back, Stand-by and Handling Charges
The results of the automated monitoring activities will be disseminated to each hospital and/or service center for review. The hospital and/or service center must review the results and confirm those identified as exceptions. If the facility confirms that an overpayment has occurred, the facility must rebill the account within 30 days of confirmation or as specified by payer specific rules and timeframes, take corrective action to prevent future occurrences within 60 days, and for federally-funded payers, forward the completed overpayment tracking worksheet within 30 days to Regulatory Compliance Support for entry into the Overpayments Tracking System. Refer to the overpayment worksheet and corresponding instructions for detailed information on completing the worksheet.
B. Hospital-Based Monitoring
Hospital-based self-monitors will also be used to monitor outpatient billing.
Each facility and/or service center must monitor each policy and procedure as specified in each policy. The monitors must be completed within the timelines established by, and in accordance with, the monitoring instructions included with each policy.
  1. The results of both monitoring activities must include review by an Oversight Group. The Oversight Group can be a separate committee such as a “Facility Billing Compliance Committee” or a sub-committee of the Facility Ethics and Compliance Committee.
  1. This Oversight Group must consist, at a minimum, of the following individuals:
a)Chief Financial Officer;
b)Business Office Director and/or Patient Access Director;
c)Ancillary Department Director (e.g., Laboratory Director);
d)Health Information Management Director; and
e)Other individuals as deemed appropriate (e.g., Admitting Supervisor, Billing Supervisor, Revenue Integrity personnel, Utilization Management personnel, Medicare Service Center personnel, Patient Account Services personnel, Physician Advisor).
  1. The Oversight Group must meet routinely, but no less than quarterly, and will be responsible for:
a)Reviewing the results of the monitoring activities;
b)Maintaining documentation that describes the monitoring process, the results of the review and action taken as a result of the review. The documentation should contain, at a minimum, the following elements: date, testing performed with the monitoring tools, error rates, action taken, status of action in place, dates of rebills, and corrective action plans for meeting the terms of the Corporate Integrity Agreement;
c)Managing the monitoring process; and
d)Developing meeting minutes.
The Facility Ethics and Compliance Committee is responsible for implementation of this policy within the facility.
REFERENCES: The Office of Inspector General’s Compliance Program Guidance For Clinical Laboratories (August 1998) pgs. 27-28

2/2006