PSOW 2016 - Compliance

1. COMPLIANCE
ANYONE DOING IT???
Dan Williams

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?

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

15. COMPLIANCE
EXCLUSIONS LIST?
What is this?
How many of you check it?
What if I have an employee on the list?
https://exclusions.oig.hhs.gov/

16. COMPLIANCE
Internal Audits…
How many people are doing internal
billing audits?
If you do… How are they done?

17. COMPLIANCE

18. COMPLIANCE
DOCUMENTATION
PCR’S
WHAT DO YOURS
LOOK LIKE

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

22. COMPLIANCE
Over payments
What does that mean?
What do you have to do if you have been
overpaid?
60 DAY REPAYMENT RULE

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?

25. NOW THAT WE ARE DONE
BLOWING OFF SOME STEAM…

26. WE HAVE HIT THE FINISH LINE

27. QUESTIONS??