Compliance Programs
Today’s health care providers have many compliance concerns in addition to the laws and regulations already in existence, health care providers face continuing enforcement initiatives from the Centers for Medicare & Medicaid Services (CMS), the Office of Inspector General (OIG), the United States Department of Justice (DOJ), along with various national and state accreditation bodies. In addition to conducting federal and state payer oversight, private payers (commercial insurance payers) are also engaged in reviewing and auditing health care services for quality, medical necessity, and health care financial waste. Health care providers must have a comprehensive practice compliance program that embodies accountability, responsibility, investigation, and education. A provider’s compliance program will consist of many policies and standards based on the type of practice. Health care compliance programs should include policies and procedures designed to define laws and regulations, correct identified problems, and put controls in place to prevent any future problems.
Our health care compliance consultants address policies of compliance issues including, but not limited to:
Fraud & Abuse Awareness
Teaching Physician Rules
Marketing
Patient Risk Identification (Medication Safety, Medical Error Reduction, Patient Safety, Etc.)
Coding & Documentation
Whistle-Blower Protections
Conflicts of Interest
Business Associates Agreements
HIPAA Privacy Rules
Billing & Reimbursement
Labor Laws
Security of Health Information
Misuse of Funds and Property
Medical Records Creation/Retention
Security of Health Information
Misuse of Funds and Property
Medical Records Creation/Retention
Billing and Coding Compliance Programs
Accurate Billing and Coding Compliance should address these compliance risk areas:
- Evaluation and management coding
- Modifier usage
- CPT/ICD-9-CM/ICD-10-CM coding
- Global period coding and billing
- High-risk coding areas such as debridement (excisional and nonexcisional), interventional radiology, sepsis and urosepsis, preventive medicine
- Regulatory issues such as the proper use of the advance beneficiary notice (ABN) and local and national coverage decisions
- Payment methodologies including Medicare Severity Diagnosis-Related Groups (MS-DRGs), Ambulatory Payent Classifications (APCs), Ambulatory Patient Groups (APGs), and physician fee schedules
- Consultations and shared visits
- Midlevel provider coding
- Using the proper coding resources, including using the Internet to research regulatory or coding issues
Knowing that one of the biggest areas of risk for health care providers is the accurate claims and reimbursement submission to Medicare , our compliance consultants work with your practice to create an effective coding compliance plan.
HIPAA Compliance Programs
On December 28, 2000, the Department of Health and Human Services issued its final privacy regulations with regard to patient privacy. The regulations, required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), became effective on April 14, 2003. The Security Rules was released in February of 2003, became effective 26 months later, and are intended to accomplish four major functions:
- Ensure the confidentiality, integrity, and availability of all electronic protected health information (PHI) the covered entity creates, receives, maintains, or transmits;
- Protect against any reasonably anticipated threats or hazards to the security or integrity of such information;
- Protect against any reasonably anticipated uses or disclosures of such information not otherwise allowed by law; and
- Ensure compliance by its workforce.
