2. COMPLIANCE
WHAT DOES COMPLIANCE MEAN?
WHO’S WATCHING?
WHY DO WE NEED IT?
WHAT HAPPENS IF WE DON’T DO IT?
WHAT DO I NEED TO DO?
3. COMPLIANCE
How many of you have a compliance
program?
How many of you regularly review PCR for
Medical Necessity?
Who is responsible for making sure your
billing company has billable calls?
How Many of you know the key elements
that must be identified on each PCR?
4.
5.
6. COMPLIANCE
What Does Compliance Mean?
Meeting certain standards that are set out
by…
Individual Department
State Agencies
Federal Agencies
7. COMPLIANCE
Federal Agencies & Regulations
CMS (Centers of Medicare & Medicaid
Services)
OIG (Office of the Inspector General)
ACA (Affordable Care Act)
FCA (False Claims Act)
AKS (Anti-Kickback Statute)
8. COMPLIANCE
CMS
Set Standard for how EMS gets paid
Typically contracts with fiscal agent
Medicare Benefit Policy – Chapter 10 & 15
https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/clm104c15.pdf
https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/bp102c10.pdf
9. COMPLIANCE
OIG Office of the Inspector General
On March 24, 2003 Federal Register
ordered Creation of Compliance Programs
be implemented by Ambulance Providers
Requires 7 steps
10. COMPLIANCE
1. Compliance Policies & Procedures
2. Designation of a Compliance Officer
3. Develop Education and Training Programs
4. Internal Monitoring and Reviews
5. Responding Appropriately to Detected
Misconduct.
6. Develop Open Lines of Communication
7. Enforcing Disciplinary Standards
11. COMPLIANCE
Policies & Procedures
Training and Education
Assessment of Claim Submission Process
Pre-Billing Review of Claims
Paid Claims
Identification of Risks
Response to Identified Risks
12. COMPLIANCE
Much of this rule is in place to assure that
“Outside” influences don’t impact who gets
the call…
WHY?
$24 Million in first half of 2012
An additional $30 Million paid for transports
where NO Medicare services were provide at
either the pick-up or drop off, or anywhere
else…
13. COMPLIANCE
RED FLAGS?
Excessive Mileage
Up Coding
High number of transports per patient
SCT Code being used for…
Residence, Skilled Nursing Facility, Free
Standing Dialysis Center, etc.
14. COMPLIANCE
WHO IS WATCHING?
Seemingly every Federal Agency
WHY DO WE NEED IT
Were you asleep for the last 20 minutes?
WHAT HAPPENS IF WE DON’T DO IT?
How much money can you afford to pay in
fines for violations of the various rules
WHAT DO WE NEED TO DO?
Be prepared to do a lot of WORK
19. COMPLIANCE
How to Determine if call is an EMERGENCY?
Dispatch information
9-1-1 call or equivalent
Immediate response documented
20. COMPLIANCE
Medical Necessity
Was the transport medically necessary?
Did the Documentation paint a picture of need?
Was the patient’s problem emergent?
Could the patient have gone another way?
Is there a difference between “the patient was
assisted to the cot” and “the patient walked to the
cot?
21. COMPLIANCE
Was the patient taken to a covered
destination?
Does the PCR explain why certain
procedures were done?
Signatures, are they important?
Mileage, must be fractional mileage
23. COMPLIANCE
BILLING COMPANIES
What are they responsible for?
Do you get reports from them?
Do you ever question the methods they use
for coding?
Do they have external auditors validate their
processes?
24. COMPLIANCE
CODERS
ICD 10 CODES MUST BE USED
Who does the coding for your service?
Are your coders certified?
Does the documentation support the code that
was used?