|
A guide for physicians and other practitioners who bill for services at UCHC.
What is the purpose of the UCHC Compliance Program?
The program assures that there is a structured approach for the UCHC to remain in full compliance with all relevant laws, standards, and federal reimbursement guidelines.
What type of laws, standards, and regulations apply to the healthcare industry?
Examples include, but are not limited to: Federal False Claims Act, regulations governing participation in the Medicare/ Medicaid Programs, Stark Bill, Medicare/Medicaid anti-kickback laws, Emergency Medical Treatment and Active Labor Act, Health Insurance Portability and Accountability Act, federal regulations governing protection from research risks, state licensure laws for hospitals,
JCAHO standards, lab accreditation standards and various environmental and safety laws.
Who is responsible for the UCHC Compliance Program?
Everyone in the organization is responsible for compliance. You are obligated to:
- Comply with laws, standards, and regulations.
- Comply with policies, including the Code of Ethics which promotes honesty and integrity.
- Document accurately in the medical record and all other reports.
- Avoid conflicts of interest.
- Adhere to proper business and marketing practices.
- Ensure a safe workplace.
- Maintain a drug and alcohol free workplace.
- Maintain patient confidentiality.
How is the Compliance Program carried out?
Education is conducted so that individual faculty and practitioners understand their responsibilities to the Compliance Program. Monitoring activities are also carried out to ensure that key processes are conducted appropriately.
What common aspects of practitioners’ activities may be associated with Compliance risks?
- Medical Necessity: All health insurance programs, including Medicare are guided by “reasonableness” and “medical necessity”. If a physician certifies medical necessity of items or services fraudulently or with “reckless disregard”, he/she could be prosecuted under the Federal False Claims Act.
- Coding Practices: Practitioners are responsible to ensure the designation of proper diagnostic and treatment codes regarding services provided to their patients. Correct coding is necessary to ensure proper claims submission.
- Supervision of Residents: Attending MDs must supervise the activities of residents in order to bill for services. Documentation in the medical record must reflect the attending’s presence.
|
- Professional Courtesy/Write-off of Co-payments: The systematic waiver of deductibles or co-pays to specific populations is unacceptable. Discounted or free service may be viewed as an inducement and therefore a violation of the anti-kickback statutes.
- Documentation Practices: Documentation must be legible, chronologically correct and factual, with no whiteouts or alterations to the record. All entries must be signed and dated. Documentation must include information to support the services billed, including the patient’s diagnoses, the ordered services, documentation to support medical necessity and the service actually
provided by the practitioner in both the inpatient and outpatient settings.
- Durable Medical Equipment and Home Health Services: The Office of Inspector General has advised physicians to use due diligence in signing certifications for durable medical equipment and home health services to ensure that such services are medically necessary.
What are the consequences of non-compliance?
With regard to federal regulations, individual practitioners may be subject to civil and criminal penalties or exclusion from the Medicare /Medicaid programs. The organization may be subject to fines and exclusion from the Medicare/Medicaid programs. The organization may take disciplinary action against non-compliant individuals up to and including termination.
What do I do if I have a compliance related concern?
Practitioners have a duty to report compliance concerns. If you are uncertain if a certain policy, procedure or established business practice is appropriate to follow, seek clarification. If you are not comfortable using the internal resources available, you may call in your concern confidentially to the Reportline which operates under the UCHC Reporting and Non-retaliation Policy.
Resources for your Compliance Concerns:
- Department Chairperson
- Dr. Nancy Day Adams
Executive Director for UCHC Compliance
860-679-3501
- Corporate Compliance Integrity and Privacy Officer
Iris Mauriello, RN
860-679-3501
- Reportline: 1-888-685-2637
Additional Resources:
- Billing policies and “Tip of the Month” may be accessed in the Clinical Business Systems shared folders in UCHC email.
- The UCHC Compliance Program manual is available in the Compliance Office shared folder in UCHC email.
|
