Chapter_24_-_HC_Compliance_II_-_KMK.pptx

Chapter 24

Durable Medical Equipment, Prosthetics/Orthotics, and Supplies

Learning Objectives (I)

Familiarity with products sold by DMEPOS companies

Benefits to DMEPOS suppliers of a compliance program

Risk areas in DMEPOS supplier organizations

Duties of the Compliance Officer and the Compliance Committee

Learning Objectives (II)

Different types of compliance training

Value of open lines of communication

Techniques for auditing and monitoring

Compliance-related disciplinary action guidelines

Basic types of corrective action

Introduction

A variety of products are manufactured by durable medical equipment, prosthetic, and orthotic companies.

The DMEPOS industry is highly fragmented with over 100,000 competitors.

Some provide home care services and products, while others solely manufacture the products.

Introduction

The Medicare Modernization Act of 2003 set up a new Competitive Bidding Program for DMEPOS suppliers, under which they compete to become Medicare contract suppliers.

OIG Promotion of Compliance Program Adoption

OIG Compliance Program Guidance for the DMEPOS Industry

Variations in company size and resources, and ability to implement a compliance program

OIG seeks a commitment to objectives and principles underlying its program guidances

7 elements of a mandatory compliance program

Benefits of an Effective Compliance Program

Internal controls that ensure obedience of all laws and payor program requirements

Assessment of employee fraud behavior

Identify and prevent criminal conduct

Quickly react to employee compliance concerns

Improved quality of services delivery

Centralized source for compliance information

Thorough investigation of alleged misconduct

Reduced exposure to legal penalties

1. Written Policies and Procedures

Explain exactly how managers want employees to carry out their work tasks

Standards of Conduct – fundamental principles, values, and a framework for all activities

Policies and procedures for specific risk areas

OIG Compliance Program Guidance for DMEPOS entities lists 47 risk areas – many apply to other types of health care organizations

DMEPOS Risk Areas (I)

Billing for items or services not provided

Billing for services that the DMEPOS supplier believes may be denied

Billing patients for denied charges without a signed written notice

Duplicate billing

Billing for items or services not ordered

DMEPOS Risk Areas (II)

Using a billing agent whose compensation arrangement violates the reassignment rule

Upcoding

Unbundling items or supplies

Billing for new equipment and providing used equipment

Continuing to bill for rental items after they are no longer medically necessary

DMEPOS Risk Areas (III)

Resubmission of denied claims with different info in an attempt to be improperly reimbursed

Refusing to submit a claim to Medicare for which payment is made on a reasonable charge or fee schedule basis

Inadequate management of contracted services, resulting in improper billing

DMEPOS Risk Areas (IV)

Providing and/or billing for substantially excessive amounts of DMEPOS items or supplies

Providing and/or billing for an item or service that does not meet the quality and standard of the DMEPOS item claimed

Capped rentals

Failure to monitor medical necessity on an on-going basis

DMEPOS Risk Areas (V)

Delivering or billing for certain supplies before receiving a doctor’s order or appropriate CMN

Falsifying information on the claim form, CMN, and/or accompanying documentation

Completing portions of CMNs reserved for completion only by the treating physician or other authorized person

Altering medical records

DMEPOS Risk Areas (VI)

Manipulating the patient’s diagnosis in an attempt to receive improper payment

Failing to maintain medical necessity documentation

Inappropriate use of place of service codes

Cover letters that encourage physicians to order medically unnecessary items or services

Routine waiver of deductibles and coinsurance

DMEPOS Risk Areas (VII)

Providing incentives to actual or potential referral sources that may violate the AntiKickback Statute or other similar Federal laws

Compensation that offers incentives for items or services ordered and revenue generated

Joint ventures between parties, one of whom can refer Medicare/Medicaid business to the other

DMEPOS Risk Areas (VIII)

Billing for items or services furnished pursuant to a prohibited referral under the Stark Physician Self-Referral law

Charge limitations

Improper telemarketing practices

Improper patient solicitation activities and high-pressure marketing of non-covered or unnecessary services

DMEPOS Risk Areas (IX)

Co-location of DMEPOS items and supplies with the referral source

Non-compliance with the Federal, State and private payor supplier standards

Providing false information on the Medicare DMEPOS supplier enrollment form

Failing to meet individual payor requirements

DMEPOS Risk Areas (X)

Not notifying the National Supplier Clearinghouse of changes to the information on the DMEPOS supplier enrollment form

Misrepresenting a person’s status as an agent or representative of Medicare

Knowing misuse of a supplier number, which results in improper billing

DMEPOS Risk Areas (XI)

Performing tests on a beneficiary to establish medical necessity

Failing to refund overpayments to a health care program

Failing to refund overpayments to patients

Improper billing resulting from a lack of communication between the DMEPOS supplier, the physician, and the patient

DMEPOS Risk Areas (XII)

Improper billing resulting from a lack of communication between departments within the DMEPOS supplier

Employing persons excluded from participation in Federal health care programs

2. Designation of a Compliance Officer and Committee

CO is focal point for all compliance activities

Full-time job, access to CEO and BOD, not working in sales/marketing, appropriate authority (review documents, halt claims processing), sufficient funding and staff

Primary responsibilities of the CO

CC is managed by the CO

Primary responsibilities of the CC

3. Conducting Effective Training and Education

So employees follow compliance program rules

General training about laws & payor requirements, and Specialized training for employees in high risk areas

Curriculum for claims development and billing staff

Curriculum for sales and marketing personnel

Annual trainings, 2-4 hours per year, required participation

4. Developing Effective Lines of Communication

Between managers and employees

Facilitate reporting of complaints, questions, misconduct, and suspected violations

Several independent reporting paths

Communication channels widely publicized

5. Auditing and Monitoring

Whether employees follow program rules, and whether organization is obeying laws & regulations

Regular audits by internal & external auditors

Issues that are subjects of the audits

OIG list of auditing techniques

Audit results reported to CO, CC, senior management, and governing board

6. Enforcing Standards Through Disciplinary Guidelines

Disciplinary actions against misbehaving employees

Vary in severity depending on nature of offense

Applied consistently to all levels of employees

Background checks on new employees and new contractors

7. Responding to Offenses and Taking Corrective Actions

Immediately investigate incidents of non-compliance

If material violations found, take steps to correct and prevent

Format of the investigations

Types of corrective actions that might be taken