Yale Medical Billing Compliance Program Manual
Overview
The Yale University School of Medicine ("YSM") holds that the long-term success of its
programs is intimately tied to its reputation for integrity. The School's Medical Billing
Compliance Program is designed to safeguard and enhance that reputation by defining a
comprehensive effort to attain the Program's goals: adequately documented and
uniformly accurate medical bills issued by or through the School. Although the task of
billing may seem largely technical and generally remote from public scrutiny, experience
shows that carelessness in billing can too quickly lead to a reputation compromised by
public suspicions of wrongdoing, no matter how ill-founded. For this reason, and despite
the many competing demands on your time, we strongly urge all members of the School's
clinical community to devote significant energy and resources to making the Medical
Billing Compliance Program an effective one.
In accordance with its commitment to compliance with applicable laws and regulations
and to ethical business practices, the Yale Corporation, through its Audit Committee, has
approved the Yale University School of Medicine Medical Billing Compliance Plan (the
"Plan"), attached as Appendix A. The Plan provides the blueprint for the School's
Medical Billing Compliance Program (the "Program" or the "Billing Compliance
Program"), which encompasses all of the School's efforts to achieve correct coding and
adequate documentation and to ensure that all aspects of medical billing and collections
are handled in accordance with applicable laws and regulations. This Medical Billing
Compliance Manual has been prepared to explain the Program and to give detailed
guidance about it to those who must comply.
As the Manual describes, the Program contains educational, oversight, auditing,
disciplinary and other components. Promulgated under the aegis of the Dean of the
Medical School in accordance with the Yale Corporation's approval of the Plan, the
Program charges the Director of the Yale Medical Group ("YMG") with supervising its
implementation. Primary responsibility for day-to-day medical billing operations rests
with the Executive Director of the School's Patient Financial Services, who works closely
with the School's Director of Compliance. Each health care provider and staff member
involved in billing has an important role to play in the Program, however. The obligations
of each person covered by the Program are described in detail in this manual below.
Please read the Manual with care.
Table of Contents
I. Medical Billing Policy
It is the policy of Yale University School of Medicine to appropriately bill for
professional services provided. The University recognizes that special billing
requirements may apply to certain government-sponsored programs or to other providers.
Any such requirements must be followed. In selecting codes to describe services
rendered, University physicians, other health professionals, and billing personnel are to
select codes that they believe, in good faith, correspond to services actually rendered, as
documented in the medical record. University clinicians, other health professionals, and
billing personnel have a collective responsibility to be knowledgeable about the meaning
of the codes applicable to their area of practice, including relevant directives from billing
authorities. The University further recognizes the importance of maintaining accurate
patient accounts in accordance with applicable requirements.
University physicians, other health professionals, and billing personnel should never
submit a claim that is known to contain inaccurate information and any payments that are
received in error will be refunded.
When in doubt about how to bill a particular service, including the proper code to use, no
Program Participant should submit any claim until appropriate guidance is obtained from
departmental compliance leaders or from the Director of Compliance.
The billing physician or other health professionals are responsible for ensuring that
appropriate documentation supports the bill being submitted.
II. Does the billing compliance apply to you?
The Billing Compliance Program implements and enforces the University's medical
billing policy. A "Program Participant" is an individual who is covered by the Billing
Compliance Program and must comply with it. You are a Program Participant if you hold
one of the following positions.
1. Health Care Providers: Physicians and Others. The following four categories of health
care providers are Program Participants:
Physicians for whom the School provides billing services. You are a Program Participant
if you are a physician employed by the School on a full- or part-time basis (whether a
clinical, teaching, community- based or other physician, or moonlighting fellow) and the
School prepares and issues bills for your services.
Other health care providers for whom the School provides billing services. You are a
Program Participant if you are a nurse practitioner, a clinical nurse specialist, a
physician's assistant, a licensed social worker, licensed psychologist, or any other health
care provider employed by the School on a full- or part-time basis, and the School
prepares and issues bills for your services.
Other physicians and health care providers employed by the School. You are a Program
Participant if you are a physician or other health care provider employed by the School
either full- or part-time, charges for your services are payable to the School, and a nonSchool entity (such as a contractor) prepares and issues bills for your services.
Residents and fellows. You are a Program Participant if you are a resident or fellow at the
School who participates in the care of patients for which billing is done by the School of
Medicine. You should consult with the Director of the Yale Medical Group or the
Director of Compliance to determine when and how the Program applies to you.
2. Administrative Personnel. You are a Program Participant if you are employed as a
School administrator and are responsible for medical billing.
3. Support Staff. You are a Program Participant if you hold a support staff position at the
School and you participate in any way in the medical billing process.
4. Non-employees of YSM Who Are Involved in YSM Medical Billing. Entities and
individuals who are not employed by the School but are involved in the School's medical
billing process ("related participants") are affected by the Program. The School will
advise current related participants of the Program and will request their compliance with
it. Entities and individuals who become related participants after implementation of the
Program may be required to comply with the Program in at least four ways as a condition
of their relationship with the School: (a) attend educational programs; (b) review YSM
compliance publications; (c) accede to and assist in carrying out the Program's
monitoring functions; and (d) report potential compliance issues to appropriate
authorities.
III. School Administrators' Roles in the Billing Compliance Program
Oversight responsibilities for the Program have been assigned to several individuals and
groups in the School's administration, as described below. (Yale University officials will
also play roles in the Program's operations, as set forth from time to time in this Manual.)
1. The Dean. The Dean is responsible for implementing the Program. The Dean has
delegated certain of his responsibilities under the Program to the Chief Operating Officer
of the School (the "COO"). As the Dean's designee, the COO imposes discipline for noncompliance with the Program, in close consultation with the Director of the Yale Medical
Group (the "YMG"). Also as the Dean's delegee, the School's COO is charged with
reviewing any proposal by a clinical department (a) to use an entity other than the Patient
Financial Services (PFS) for its billing; (b) to manage its own billing compliance plan
other than through two Billing Compliance Leaders (as described in Article IV, below);
and (c) to staff the position of the Billing Compliance Resource Specialist in cooperation
with another department.
2. The Director of the Yale Medical Group The Director of the Yale Medical Group bears
primary responsibility for implementing and managing the Program. He/she supervises
the activity of the Director of Compliance, oversees the School's compliance education
and monitoring programs, and ensures that the Departmental compliance plans are
consistent with overall policies. The Director of the Yale Medical Group is responsible
for ensuring that all aspects of the Medical Billing Compliance Program are effective and
executed consistently with these policies.
3. The Medical Billing Compliance Committee. The Medical Billing Compliance
Committee ("MBCC") is chaired by the Director of the YMG . Its membership includes
the COO, the Director of University Auditing, the Director of Compliance, and
representatives from the School's clinical departments, Patient Financial Services, the
Office of General Counsel, and the Provost's Office. (Its complete membership is set out
at Appendix C.) It meets quarterly to review billing compliance issues and to address
policy questions arising in connection with the Billing Compliance Program. It
periodically reviews audit findings of internal and external audits. It is charged with
reviewing annually the status and achievements of the Plan.
4. The Director of Compliance. The Director of Compliance reports directly to the
Director of the Yale Medical Group. The Director of Compliance oversees the daily
operations of the Program, monitors each department's compliance efforts, supervises the
educational programs offered pursuant to the Program, and generally promotes and
advocates the goals of the Program. The Director of Compliance's specific
responsibilities include:
a. Coordinating compliance functions by (i) attending clinical practice meetings
conducted by the PFS; (ii) participating in MBCC meetings; and (iii)
conducting quarterly meetings of the Billing Compliance Leaders (described below).
b. Establishing and operating educational programs by (i) regularly reviewing and
revising all Program-related educational materials (including any website maintained
under the Program) in conjunction with the Office of General Counsel, PFS, and the
Director of the Yale Medical Group, to reflect changes in billing and coding protocols,
and notifying Program Participants of such changes; (ii) disseminating educational
materials related to physician billing practices and medical record documentation; (iii)
educating and training future Program Participants regarding billing, documentation, and
the Billing Compliance Program generally; and (iv) collecting, retaining and reporting
educational program test results to the Director of the Yale Medical Group and
departmental Billing Compliance Leaders.
c. Assisting the clinical departments in fulfilling their billing responsibilities by (i)
working with the departments to develop tailored educational resources and facilitating
department-based training programs and; (ii) performing independent evaluations of
departmental compliance.
d. Evaluating YSM compliance efforts by (i) training compliance audit staff to conduct
audits of billing and documentation; (ii) monitoring billing, coding and documentation
practices used throughout YSM; (iii) conducting independent evaluations of a department
if a problem is suspected or an inquiry is received; and (iv) reviewing a sample of
medical records and corresponding bills for each department at least annually.
e. Investigating complaints of noncompliance received by the YSM Hotline or other
means.
f. Monitoring proposed employment by determining whether any person or supplier to
whom YSM proposes to extend an offer of employment has been sanctioned or excluded
from participation in any government programs.
g. Preparing the School's Annual Medical Billing Compliance Report, which describes
compliance efforts and results achieved during the year.
h. Assist with medical billing policy development as needed by the departments, faculty
and PFS.
5. Patient Financial Services The Patient Financial Services ("PFS") and the Associate
Director of the Yale Medical Group are charged with ensuring accuracy and
completeness in the School's billing process and related information systems. In
particular, PFS:
a. Ensures the availability of up-to-date billing tools, such as encounter forms, through
annual review of the forms and revision as necessary.
b. Holds regularly scheduled meetings with each clinical department to discuss procedure
code and other issues related to the Billing Compliance Program. PFS apprises the
Director of Compliance of any departmental compliance issues that arise.
c. Distributes materials regarding compliance, such as newsletters received from
insurance carriers, to appropriate Program Participants.
d. Works with the Director of Compliance on providing training for PFS staff and the
administrators of the clinical departments connected with billing. Every two years, PFS
will provide a minimum of one hour of medical billing training to PFS employees and to
each of the departmental clinical administrators.
e. Facilitates responses to routine requests for medical records (i.e., requests made other
than in conjunction with an audit).
f. Ensures that refunds for payments erroneously made to the School are handled properly
and in accordance with the Credit Balance Corrective Action Plan of September 1998 as
revised August 2000 and December 2002..
IV. Departmental, Physician and Related Responsibilities
1. Departmental Obligations. Each clinical department is expected to:
a. Prepare a written plan addressing compliance efforts on a departmental basis, to be
reviewed and approved by the Director of the Yale Medical Group (Appendix A,
Compliance Plan, Departmental Implementation Plans)
b. Develop departmental expertise in documentation, coding, and billing, and maintain
resources to aid providers in achieving accurate billing.
c. Appoint one departmental faculty member and one administrator to serve as the
department's "Billing Compliance Leaders," with responsibilities described below.
d. Appoint a suitable individual or individuals from among its members (or, in small
departments and with the approval of the COO, from a cooperating department), to serve
as its "Billing Compliance Resource Specialist" (BCRS). The BCRS may be a clinical
practice specialist, a coding specialist certified in physician coding, a certified procedural
coder, a registered record administrator, or an accredited record technician. Large or
high-volume departments may require more than one BCRS.
e. In response to requests by the Compliance Department, provide copies of inpatient,
outpatient and office medical records for the purpose of facilitating internal and external
audits.
f. Assist in implementing corrective measures responsive to internal auditing results when
deemed appropriate by the Director of the Yale Medical Group (Senior Associate Dean) .
g. Timely perform related administrative tasks, including: (i) initiating corrective action
on overpayments identified by the department or the Compliance Department including
timely notification to PFS and department verification of corrective action; (ii) sending
copies of all correspondence with insurance carriers regarding billing or compliance to
the Director of Compliance, who monitors all such correspondence; (iii) submitting all
draft departmental training materials regarding billing and documentation to the Director
of Compliance for review and approval in advance of use; and (iv) notifying the Director
of Compliance of any proposed outside affiliation, for review in accordance with the
Excluded Persons Policy (Appendix B).
h. Support departmental employees in maintaining their status as Certified Procedural
Coders, or other credentials that ensure the department has current coding expertise.
i. Maintain a record of all its outside affiliations with other health care provider
institutions, and the related bills, and provide the Director of Compliance a list detailing
any such affiliation before billing for the affiliated party.
j. Request a review of contracts with outside affiliations, including YNHH, by the
General Counsel's Office, PFS and the Compliance Department as appropriate.
2. Billing Compliance Leaders. The two Billing Compliance Leaders in each clinical
department are charged with managing the department's compliance-related tasks and
overseeing the department members' compliance with the Program. The Billing
Compliance Leaders are expected to work closely with School administrators in fulfilling
departmental obligations. A department desiring to oversee the effectiveness of its
Compliance Program by a mechanism other than Billing Compliance Leaders must
propose its alternative to the COO in writing and should have COO approval before
proceeding. The person assigned the billing compliance leader position may be changed
every two years or as needed.
As a part of their general duties, the Billing Compliance Leaders will:
a. Conduct regular intradepartmental discussions of compliance, billing practice, and
documentation issues.
b. Develop and coordinate departmental educational programs and materials related to the
Program.
c. Assist as needed with questions raised by the Compliance Department relating to
compliance audits and other compliance activity of the department
d. Conduct departmental follow-up meetings with faculty and staff to discuss the results
of Compliance Program monitoring.
e. Attend quarterly meetings with the Director of Compliance and Billing Compliance
Leaders from other departments.
f. Review and revise as necessary the departmental compliance plans
g. Participate in and approve annual encounter form updates
h. Assist with ensuring 100% compliance with the training requirement for their
department and as needed with the development and coordination of departmental
training programs.
3. Billing Compliance Resource Specialist. The Billing Compliance Resource Specialist
will develop expertise in billing and coding protocols applicable to the department
operations, and serve as a compliance resource for others in the department.
4. Particular Obligations of Physicians and Other Healthcare Providers. All physicians
and other health care providers must assume accountability for their own medical record
documentation and the corresponding diagnosis and procedure codes that appear on bills
they submit for reimbursement. They must document medical records and assign billing
codes in accordance with government regulations and in a timely and accurate manner.
5. Physician Educational Requirement. Annually , all billing physicians covered by the
Program must complete one hour of medical billing compliance training. This
requirement may be met in various ways. The first option is for physicians to participate
in the Teaching Regulations Training Module published at the Yale Teaching Physicians
website (http://learn.med.yale.edu/cms/caslogin.asp). Physicians may also meet the
training requirement by electing alternate programs offered by the Compliance
Department such as seminars, video training, audit selection, or other programs.
New faculty must complete the Teaching Regulations Training Module and pass the
accompanying test within a reasonable time after beginning employment at the School.
Billing privileges may be suspended if a new faculty member does not timely comply
with this requirement. The requirement may also be met by new faculty participating in a
training session with the Compliance Department.
A list of all participants and associated training activity will be maintained by the
Director of Compliance, who will report the results to the Director of the Yale Medical
Group and the relevant Billing Compliance Leaders.
V. Obligation of all Program Participants
All Program Participants must:
(1) familiarize themselves with the Program and with applicable coding and
documentation requirements;
(2) attend all mandatory training sessions;
(3) keep abreast of changes in the Program and coding and documentation procedures;
(4) bill correctly and in good faith, and document adequately; and
(5) promptly refund payments received in error.
VI. Compliance Guidelines
Coding and Documenting Bills
The individual health care provider who provides a service bears the primary
responsibility for accurately assigning procedure and diagnosis codes and adequately
documenting the services rendered that they in good faith believe correspond to the
services they render that are documented in the medical record.
YSM abides by medical billing standards issued by the Center for Medicare and
Medicaid Services ("CMS"), and, as appropriate, the American Medical Association
("AMA") in its book of Current Procedural Terminology (the "CPT" book) and the CMS
Teaching Physician Guidelines. Program Participants are expected to familiarize
themselves with the CMS/AMA standards.
In case of a dispute among Program Participants, the Director of the Yale Medical Group
is responsible for resolving the issue.
Program Participants are expected to bring possible coding errors to the attention of the
relevant provider.
Entering Charges into the YSM- or Related Computerized Billing Systems
A Program Participant must never enter a charge, or submit or process a claim or bill that
he or she knows to contain any inaccurate information concerning the service provided,
the charges, the identity of the provider, the date of service, the place or service, or the
identity of the patient.
Except as provided below, bills generated by Program Participants must be entered into
the YSM computerized billing system and issued by the Patient Financial Services
("PFS").
Bills may be prepared by and issued through other than by PFS with the written approval
of the School's Chief Operating Officer and the Director of the Yale Medical Group. To
obtain approval for an alternative arrangement, the requesting Department should
document its proposed arrangement, its past practice (if relevant), and its reasons for the
departure from standard practice, and submit its request in writing to the COO and the
Director of the Yale Medical Group.
Managing Uncertainty in Billing When you are uncertain about how to bill for a
particular service or what code to use, you must resolve that concern to the best of your
ability before submitting a bill. Address your question to the following people in the
following order, to the extent feasible:
First, to your immediate supervisor or clinical administrator, who may consult with your
Department's Billing Compliance Resource Specialist, Billing Compliance Leaders, or
other knowledgeable Departmental billing personnel.
Second, to PFS's Associate Director, Patient Accounts.
Third, to the Director of Compliance.
If the question has still not been resolved to your satisfaction, you may contact either the
Executive Director of PFS, the Director of the Yale Medical Group, the Dean, or the
University's Office of General Counsel or the Medical Billing Hotline
VII. Hiring: The Excluded Persons Policy
The School is not allowed to bill for services rendered by certain "excluded persons" individuals who have been sanctioned by the United States Government or excluded from
participation in federal programs.
The School abides by federal requirements pertaining to the employment of individuals
who have been sanctioned by the United States Government or excluded from
participation in federal programs.
1. Excluded Persons Policy. The School will follow the Excluded Persons Policy set forth
at Appendix B regarding its relationship with any individual who has been sanctioned or
excluded by the United States Government from participating in federal programs.
2. Credentialing Office Review. When the credentialing process is initiated, the
Credentialing Office will request that the Compliance Office confirm that the individual's
name does not appear on the CMS/OIG excluded persons and cumulative sanctions lists.
The Credentialing Office will report the name of the individual hired, the hiring
department, and the effective date of employment to the Compliance Office promptly
after receiving notice of the hire.
The Excluded Persons Procedure can be found in its entirety at:
http://info.med.yale.edu/ymg/comply/alert/exdebar.html
VIII. Education Program
Working through the Departments and the Director of Compliance, the YSM will strive
to educate all Program Participants with respect to obligations imposed by the
Compliance Program and related laws, regulations and protocols. The YSM intends that
every employee involved in professional fee billing shall at a minimum receive the
equivalent of one hour of compliance training every year.
1. General Policies.
a. Education and training may occur through a variety of media, including e-mail,
newsletters, memoranda, presentations, online training, and formal programs.
b. Education may be provided centrally by the Compliance Department or at the
Department or section level.
c. The Director of Compliance will ensure that Program Participants receive timely
updates on changes in billing and coding regulations or protocols.
d. The YSM will regularly review and revise all educational materials to reflect changes
in billing and coding protocols.
e. Participation in certain educational and training programs will be made available to
Program Participants.
2. Oversight by the Director of Compliance. The Director of Compliance will oversee
YSM and departmental educational programs regarding compliance and assure
consistency in their content insofar as possible, and will review all training materials
developed by the departments. The Director of Compliance will inform the faculty and
staff of changes in documentation requirements and teaching physician guidelines, and
will advise of incorrect billing practices and areas of abuse targeted by the Department of
Health and Human Services Office of the Inspector General ("DHHS/OIG") or other
external enforcement agencies. With respect to these tasks, the Director of Compliance
will collaborate with other key administrators, including the Director of the Yale Medical
Group, the General Counsel, the Director of University Auditing, the Executive Director
of PFS, and departmental administrative leadership.
3. Training by the Patient Financial Services. The Patient Financial Services will annually
provide PFS staff and department clinical administrators at least one hour of compliance
training with respect to billing and the Billing Compliance Program at least every two
years.
4. Departmental Education. With the assistance of the Director of Compliance, the
clinical departments may develop and operate educational and training programs focusing
on particular coding and other issues relevant to their specific clinical practices.
Departments should use the results of their own compliance monitoring efforts in their
educational programs. The Director of Compliance will monitor the effectiveness and
consistency of such programs.
IX. AUDITS
External Audits.
a. Audit notice. The federal government and other third party payors periodically audit
the bills of health care providers. Any individual at YSM who receives notice of such an
audit shall immediately advise and provide the Director of Compliance with a complete
copy of the notice. The Director of Compliance will notify the Executive Director of PFS
and the Director of the Yale Medical Group.
The Executive Director of PFS and/or Director of the Yale Medical Group will thereafter
promptly notify the Medical Director, the COO, the General Counsel, the Chairman of
the Department involved, and the Director of University Auditing of the audit notice.
All contact with the entity initiating the audit will be coordinated by the Director of
Compliance.
b. Requests for medical records. An audit notice may contain a request for medical
records. Multiple requests for medical records generally indicates that an audit is
underway even absent an audit notice. Requests for medical records may be received
directly by departments or the physician being audited. In these situations, a copy of the
request should be promptly sent to the Director of Compliance by the department or
physician.
In order for the Director of Compliance to respond to such requests for medical records,
the department will promptly gather and collate two copies of each of the medical records
requested, retain one, and provide one to the Director of Compliance. The Director of
Compliance will conduct a preliminary review of the requested medical records and
associated bills and report his or her findings to the audit response team.
c. Response to external audit. Under the management of the Director of Compliance and
with input from the Executive Director of PFS, the Director of the YMG , the General
Counsel's Office, the Office of University Auditing, and an appropriate Departmental
representative the School's response to the audit will be formulated. Possible actions
include identifying potential billing problems, communicating with the physician being
audited, and communicating with the party conducting the audit.
d. Completed audits. The Director of Compliance will review any correspondence related
to an audit, including any document reflecting the results of the audit. The Director of
Compliance and Billing Compliance Leaders will conduct any appropriate follow-up to a
completed audit with the health care providers and staff involved. Generic material or
information generated by an audit may be incorporated into educational materials and
activity.
e. Records related to an external audit. The Compliance department will maintain copies
of the medical records produced in connection with an external audit for at least seven
years after the close of an audit.
f. Summary of audits. The Director of Compliance will provide quarterly, annual and
cumulative summaries of the audits conducted at the School to the Director of the Yale
Medical Group. The Director of the Yale Medical Group will provide a summary of audit
results to the MBCC at its meetings.
2. Internal Audits
The Director of Compliance and associated compliance staff will conduct regular internal
reviews of billing and documentation activity at the School. The Director of Compliance
will prepare an annual Audit Plan outlining the internal audits to be conducted. The audit
plan will be based on:
Areas targeted in the Office of Inspector General's Work Plan for the current year
The results of last year's compliance audits
Individual physicians who request a compliance audit
Areas identified by the local Medicare carrier through its' newsletter or other media
New physicians
Teaching Physician Quiz Scores
Randomly selected services
Office of the Inspector General's Chief Financial Officer's audit results
The audit plan will be prioritized and will be a flexible document allowing for audits to
be added, revised or deleted in response to shifting priorities.
The Compliance Department will conduct audits using standardized procedures and audit
tools to ensure quality and consistency of audit results. The Director of Compliance will
respond to the results of an internal departmental audit by addressing comments, when
appropriate, to the healthcare provider, the Billing Compliance Leaders, and, if necessary,
the department Chair. The Director of Compliance will provide summary results of the
internal audit to the Dean, the COO, the Director of the Yale Medical Group, the General
Counsel and the Director of University Auditing. The Compliance Department must give
health care providers prompt feedback on their individual performances to allow for
timely correction of improper practices
X. Service of Process; Subpoenas
Any School employee who receives legal process, such as a summons or subpoena, must
immediately notify the General Counsel (phone: 203/432-4949) and provide the General
Counsel a copy thereof. If the legal process received involves medical billing and
compliance, the School employee must also notify the Executive Director of PFS or the
Director of the Yale Medical Group, who will in turn notify the Director of University
Auditing, the COO, and the Director of Compliance. The School employee must
thereafter forward all relevant documents to the General Counsel, in accordance with
instructions from that office.
XI. Record Retention System
Connecticut law mandates that the School retain certain records for prescribed lengths of
time pertaining to the delivery of medical services. The University also desires to
maintain certain records demonstrating its commitment to compliance. For these reasons,
the School has instituted the following record retention policy, which applies to paper
records and to those maintained on computer, magnetic tape, or in another electronic data
processing storage medium. All such records should be amenable to ready retrieval upon
demand.
1. Legal Requirements. Connecticut law requires that records are maintained as follows
(Conn. Agencies Regs. ss 19a-14-41 through 19a-14-43):
a. Retain all parts of a medical record for seven (7) years from the date of last treatment,
or for three (3) years after the death of a patient.
b. Retain pathology slides, EEG and ECG tracings for seven (7) years, but if an ECG is
taken and the results are unchanged, then only the most recent result need be retained.
Reports regarding each of these slides or tracings must be retained for the life of the
medical record.
c. Retain positive (abnormal) laboratory and PKU reports for at least five (5) years.
(Under the regulations, negative reports need not be retained.)
d. Retain x-ray films for three (3) years.
e. If a claim of malpractice, unprofessional conduct, or negligence with respect to a
patient has been made, whether or not litigation has actually commenced, retain all
records regarding that patient until the matter is finally resolved.
f. "A consulting health care provider should retain records if they are sent to the referring
provider, who must retain them." (Note: YMG requires the consulting health care
provider to retain a signed copy of the letter sent to the referring provider in the patient's
medical record to support any billings that may have been generated.
g. An initial health care provider is not required to retain records that he or she sends to a
new primary provider upon a patient's written request. (Note: It is recommended that a
copy of the records be kept to support any billings that may have been generated.)
2. Additional Requirements. In addition, the School has instituted the following policies
regarding the retention of records.
a. Retention of affiliation records. The School requires that clinical Departments maintain
copies of records related to their affiliations with outside institutions, including related
billing records, for seven (7) years.
b. Document destruction policy. Disposal and destruction of documents, including by
shredding, must be done in accordance with any applicable departmental or School
policy. Documents containing social security numbers, medical diagnoses, and insurance
policies, should be destroyed by shredding. All record destruction procedures must be
amenable to being halted rapidly, in response (for example) to service of legal process.
c. Privacy and security. Record creators, record users and record keepers at the School
must use their best efforts to ensure the privacy and security of medical records and in
accordance with the relevant federal and state guidelines.
d. Privileged documents. All privileged documents must be segregated and clearly
marked. For purposes of this requirement, "privileged documents" means any document
covered by the physician-patient, therapist-patient, attorney-client, attorney work product,
or other legal privilege or doctrine protecting it from production during legal
proceedings.
3. Retention of Insurance Carrier and Government Correspondence. All correspondence
that relates to billing issues between any insurance carrier and the School or any of its
constituent parts (including all individuals employed by the School)) must be retained for
seven (7) years. Copies of all such correspondence which pertain to medical billing issues
should be sent by the School employee to the Director of Compliance and to PFS.
Correspondence that must be retained includes, but is not limited to:
letters received in response to a request for a policy clarification;
billing instructions;
fee schedules; and
statements of policy or policy changes.
For purposes of this section, "insurance carrier" means a Medicare carrier or
intermediary, a private insurer, or any state or government agency.
4. Retention of Documents Connected with External Audits. The Compliance Department
will maintain a copy of all medical records and correspondence related to an external
audit in a secure location for seven (7) years.
Note: If any Department or clinical activity is subject to more stringent medical record
retention requirements than the requirements listed in this policy, the more stringent
requirements apply. These more stringent requirements may include rules imposed by the
federal government or an accrediting body.
XII. Reporting Compliance Issues
1. General Principles. Each Program Participant must comply with the Program and is
expected to report instances of suspected non-compliance to School or University
officials, as described below. Employees who in good faith report possible compliance
issues will not be subject to retaliation or harassment for the report. Any concerns
regarding apparent or possible retaliation or harassment should be addressed to the COO
and the General Counsel.
2. Reporting System for Potential Compliance Issues. The School will operate a
confidential reporting system for potential compliance problems that is accessible to all
faculty, staff, and other individuals. Individuals may make such reports either via a
telephonic hotline, orally, or in writing to the Director of Compliance, departmental
management staff, the Office of General Counsel, or the Director of University Auditing.
All School employees will be advised of the hotline reporting system and the opportunity
to report billing compliance concerns in writing. All inquiries, reports, or complaints
must promptly documented and transmitted to the Director of Compliance and the
Director of University Auditing. The Director of University Auditing will maintain the
hotline reporting system and serve as liaison with any provider of a hotline service that
may be retained. Upon the complainant's request, his or her anonymity will be preserved
to the extent practicable.
3. Logs of Reports. The Director of Compliance will maintain a confidential log of
compliance concerns reported directly to him or her and/or the Director of the YMG ,
recording the issue complained of, the departments or divisions affected, the status of the
investigation, if any, and any issues remaining to be resolved. The log will also reflect the
source of the complaint, and will maintain the anonymity of the complainant to the extent
practicable. Access to the log will be limited to the Director of the Yale Medical Group,
the COO, General Counsel, Director of University Audit, and other individuals as
determined by the Director of Compliance as needing to have access in order to perform
their duties. All documents reflecting an allegation regarding medical billing compliance
will be maintained in a confidential manner. The Director of Compliance will keep the
Director of YMG apprised of all open compliance concerns during their weekly
meetings.
The Director of University Auditing will maintain a confidential hotline log reflecting
any billing complaints received by the hotline and the results of the investigation of those
complaints.
The Director of Compliance will forward on at least an annual basis a copy of the report
log to the COO, Director of the Yale Medical Group and the General Counsel.
4. Response to Allegations, Inquiries, or Complaints. The Director of University Auditing
will contact the COO, Director of the Yale Medical Group and the General Counsel to
determine a suitable response to particular allegations, inquiries, or complaints. In
consultation with the General Counsel, the Director of University Auditing will
determine whether alleged wrongdoing appears to amount to a violation of state or
federal law, regulation or policy, whether it conflicts with the School's Medical Billing
Compliance Program, poses a risk to the general public, or could put the School at risk of
economic or reputational injury. On the basis of that determination, and in further
consultation with the COO, General Counsel, Director of the Yale Medical Group, and
the Director of Compliance, the Director of University Auditing will designate a
University official to investigate the allegation.
5. Summary Reports of Allegations and Investigations. The Director of Compliance will
include in the quarterly report to the COO and the Director of the Yale Medical Group a
summary of all compliance-related allegations, inquiries or complaints received and
investigations conducted during the quarter. The Director of University Auditing and the
Director of Compliance will disclose the fact and substance of any allegations, inquiries
and reports only to the COO, Director of the Yale Medical Group, members of the
Medical Billing Compliance Committee, the General Counsel, and their respective
representatives having a need to know. The Director of University Auditing will closely
monitor the progress of any investigation.
XIII. Investigating Compliance Issues
It is the School's policy to investigate allegations of non-compliance within a reasonable
time after the allegation is received.
1. Investigatory Authority. If the Director of the Yale Medical Group determines that
there is reasonable cause to believe that a compliance issue may exist, an inquiry will be
undertaken. The Director of University Auditing will assign responsibility for
investigating a hotline report to University officials on a case by case basis, and in
consultation with other administration officials. The General Counsel will aid in the
determination whether the School should retain an external consultant to conduct the
investigation. The Director of University Auditing will timely advise the Director of
Compliance of the identity of the investigator assigned to inquire into complaints
received (if the Director of Compliance is not the investigator). The Director of
University Auditing is authorized to investigate any function or individual upon his or her
own initiative, reasonably exercised, and nothing in the Program limits that authority.
2. Investigative Process. At the start of an investigation, the General Counsel, the
Director of University Auditing, COO, the Director of the Yale Medical Group, and the
Director of Compliance will discuss its nature, determine an appropriate course of action
including who will investigate the complaint, and set a timetable for completion.
Investigations will be conducted as confidentially as possible under the circumstances.
Investigators and their assistants will respect the privacy concerns of both complainant
and the subject or subjects of the complaint. Records related to the investigation and to
the reports of wrongdoing will be preserved in accordance with law and so as to assure
their protection under the attorney-client privilege and attorney-work product doctrine, as
applicable.
3. Findings. The investigator will provide interim reports, as requested, and written
investigative findings to the Director of the Yale Medical Group, the General Counsel,
the COO, the Dean, the Director of University Auditing, and the Director of Compliance.
XIV. Corrective Action Whenever a compliance issue has been identified, the School will
take action to remedy the problem, mitigate the harm done, and prevent a recurrence. The
type of corrective action instituted will depend on the nature and gravity of the noncompliance found.
1. Authority The Director of the YMG in consultation with the Dean has final authority
for directing corrective action in response to a finding of noncompliance. In formulating
an appropriate course of corrective action, the Director of the YMG will consult with the
COO, Executive Director of PFS, the Office of General Counsel, the Director of
Compliance, and the Director of University Auditing, (and may consult with the COO
and the Dean). The corrective action plan adopted will be set forth in writing. .
2. Process. Corrective actions will be set forth in writing and delivered to the individuals
required to comply. Corrective actions will be designed to address provider-specific
issues and to ensure that similar issues in the billing process are addressed in other
departments.
3. Follow-up. Once corrective action has been taken, its effectiveness will be evaluated
by the Director of Compliance as needed, or within a reasonable time after the corrective
action has been completed. The Director of Compliance will discuss the findings of the
evaluation with the health care provider or other involved individual, the applicable
Billing Compliance Leaders, and the Director of the YMG . The Director of Compliance
and the Director of the YMG will jointly determine whether any further corrective action
is necessary or appropriate.
XV. Discipline and Enforcement
1. General Policies. Compliance with the Plan is an essential element of the job
responsibilities of all Program Participants. Program Participants who fail to adhere to the
Plan may face disciplinary action, and their professional evaluations may reflect these
failures. The School has a policy of progressive discipline and sanctions for infractions
committed by an employee, including non-compliance with the Plan; in instances of
gross misconduct, however, immediate disciplinary action, up to and including
termination, may result. Whether the prohibited conduct was undertaken recklessly or
willfully will be weighed heavily in administering discipline and sanctions.
2. Disciplinary Action. Corrective action for non-compliance, determined by the Director
of the Yale Medical Group, may include a recommendation that the Dean impose a
sanction or disciplinary action against a non-complying individual. The Dean has
delegated his authority to effect discipline for non-compliance with the Program to the
COO. Individuals who have demonstrated a propensity toward behavior that raises
compliance concerns may be restricted from billing. Other possible disciplines include,
for example: requiring attendance at additional training at the expense of the individual;
having billing activity monitored regularly by an external billing expert, retained at the
expense of the individual involved; reprimand; probation; and suspension or termination
of employment.
3. Notification. Through publication and dissemination of this Manual, the School is
advising all faculty, staff, other Program Participants, and related participants of the
Billing Compliance Program and its requirements, the importance of adhering to the
Program as a material condition of their employment, and the possible consequences of
non-compliance, including immediate termination of employment. Program Participants
will be notified of subsequent significant revisions to the Compliance Manual.
4. Consequences of Non-compliance for Related Participants. Non-compliance by related
participants (entities that bill for services rendered by the School or perform services for
which the School bills) may result in (a) termination of the person's or entity's agreement
with the School; (b) a demand for reimbursement for any losses or damages resulting or
required from the violation; or (c) other responsive actions, including referral to
enforcement agencies, as permitted or required by law.
XVI. Annual Review and Report
1. External Monitoring. The University may retain qualified external experts to review all
or part of the Program, identify its strengths and weaknesses, make recommendations,
and assist in implementing modifications to the Program.
2. Annual Compliance Audit. On an as needed basis, the Director of University Auditing
will conduct an audit of the University's current medical billing operation to determine
whether there are sufficient controls in place to assure that federal health insurance
programs and other insurers are billed appropriately for services rendered. He or she will
submit this report to the Audit Committee on or before July 15.
3. Annual Reporting. Annually, on or before each July 31, the Director of Compliance
will prepare a report on the effectiveness of the Program in the preceding financial year
and will make recommendations for improvement as needed. The Annual Medical Billing
Compliance Report will also include at least the following elements:
a summary of general compliance activity undertaken during the preceding year,
including any changes made to the Compliance Plan;
a copy of the Hotline log for the preceding year;
a copy of the audit report if conducted by the Department of University Auditing;
a description of actions taken to ensure the effectiveness of the training and education
efforts; and
a summary of actions taken to ensure compliance with the University's policy on dealing
with excluded persons.
The Director of Compliance will distribute the Annual Medical Billing Compliance
Report to the Director of the Yale Medical Group, the Department Chairs, the General
Counsel, the Director of University Auditing, the Dean, the COO, the Medical Billing
Compliance Committee and to others with an interest in compliance, for their comments
and suggestions for revisions to the Program.
The Director of the Yale Medical Group will transmit the Annual Report to the
University Audit Committee that is chaired by the Provost and the Audit Committee of
the Yale Corporation.
GLOSSARY
AMA
American Medical Association
BCL
Billing Compliance Leader
BCRS
Billing Compliance Resource Specialist
CPT
Current Procedural Terminology
CPC
Certified Procedural Coder
CMS
Center for Medicare and Medicaid Services
DHHS
U.S. Department of Health and Human Services
GME
Graduate Medical Education
HCFA
Health Care Financing Agency, a United States Government Agency (now CMS)
MBCC
Medical Billing Compliance Committee
OIG
Office of Inspector General
PFS
Patient Financial Services
YSM
Yale School of Medicine
YMG
Yale Medical Group
APPENDIX A
YALE UNIVERSITY SCHOOL OF MEDICINE
MEDICAL BILLING COMPLIANCE PLAN
Introduction
The Yale University (the "University") has an ongoing commitment to ensuring that its
activity are conducted in accordance with applicable law and sound and ethical business
practice. The University also has a strong interest in making certain that its faculty and
employees are fully informed about applicable laws and regulations so that they do not
inadvertently engage in conduct that may raise compliance issues. Of particular concern,
given the fact that many medical school faculty engage in clinical practice, are legal
requirements relating to professional fee billing. Compliance in this area is challenging
because the regulatory requirements governing professional fee reimbursement are
complex and changing. To further its commitment to compliance and to protect its
employees, the University has decided to formalize its compliance plan to address
professional fee reimbursement. The compliance plan has the following key features:
Designation of University officials responsible for directing the effort to enhance
compliance, including implementation of the Plan;
Incorporation of standards and policies that guide University personnel and others
involved with the billing process with regard to professional fee billing;
Development of compliance initiatives at the Department level;
Coordinated training of clinical staff and billing personnel concerning applicable billing
requirements and University policies;
A uniform mechanism for employees to raise questions and receive appropriate guidance
concerning professional fee billing;
Regular chart and billing reviews to assess compliance, to identify issues requiring
further education, and to identify potential problems;
A process for employees to report possible compliance issues and for such reports to be
fully and independently reviewed;
Formulation of corrective act ion plans to address any compliance problems that are
identified; and
Regular reviews of the overall compliance effort to ensure that billing practices reflect
current requirements and that other adjustments are made to improve the program.
The compliance program described in this document is intended to establish a framework
for legal compliance by the University and its employees. It is not intended to set forth all
of the substantive programs and practices of the university that are designed to achieve
compliance. The University already maintains various compliance practices and those
practices continue to be a part of its overall compliance efforts.
Scope
The Plan applies to billing for clinical activity by Yale physician faculty that takes place
within the scope of their employment at the Yale Medical Group (YMG). It includes the
activity of the YMG as well as any situations where some other entity or group handles
YMG billing. The Plan applies to all faculty, housestaff, fellows, and any other persons
who are involved in YMG billing.
Administrative Responsibility
Primary responsibility for implementing and managing the University's medical billing
compliance effort shall be assigned to the Director of the Yale Medical Group . The
position of Director of Compliance will be created and will report to the Director of the
YMG . The Director of Compliance will, with the oversight of the Director of the YMG
and the assistance of University counsel where appropriate, perform the following
activity:
1. Assist in the review, revision, and formulation of appropriate policies to guide billing
of professional fees by organizations that bill for services provided by University medical
faculty;
2. Work with Departments and faculty to develop plans for implementing University
policies on billing;
3. Assist in developing and delivering educational and training programs;
4. Work with Departments and faculty to develop and/or enhance billing expertise and to
facilitate Department based training programs;
5. Coordinate reviews of medical charts and associated billings; and
6. Provide other assistance as directed by the Director of the YMG
The Director of Compliance shall work closely with representatives of the Departments
and any entities or individuals who handle professional fee billing for the University's
faculty physicians to foster and enhance compliance with all applicable billing
requirements.
Policy Guidelines
The policy of Yale University is to bill only for professional services provided. The
University recognizes that special billing requirements may apply to certain governmentsponsored programs or to other providers; any such requirements must be followed. In
selecting codes to describe services rendered, University physicians, other health
professionals, and billing personnel are to select codes that they believe, in good faith,
correspond to services actually rendered, as documented in the medical record.
University clinicians, other health professionals, and billing personnel have a collective
responsibility to be knowledgeable about the meaning of the codes applicable to their
area of practice, including relevant directives from billing authorities. The University
further recognizes the importance of maintaining accurate patient accounts in accordance
with applicable requirements.
University Physicians, other health professionals, and billing personnel should never
submit a claim that is known to contain inaccurate information concerning the service
provided, the charges, the identity of the provider, the date of service, the place of
service, or the identity of the patient. Payments that are received in error will be refunded.
When in doubt about how to bill a particular service, including the proper code to use, no
claim should be submitted until appropriate guidance is obtained from departmental
compliance leaders or from the Director of Compliance. The resolution of any such
billing questions should be documented in writing.
It is the responsibility of the billing physician or other health professional to ensure that
appropriate documentation supports the bill being submitted.
To guide physicians, other health professionals and billing personnel in meeting these
objectives, the Director of the Yale Medical Group shall, with the assistance of legal
counsel, review existing policy statements, revise those statements as necessary, and
develop any additional statements that seem advisable. University policies concerning
billing, as those policies may be changed periodically, should be considered an integral
part of this Plan. A copy of the University's policy in dealing with excluded persons is
attached to the Plan and incorporated herein.
Departmental Implementation Plans
Each clinical department shall appoint a faculty member and an administrator to serve as
the compliance leaders for departmental billing activity. The departmental compliance
leaders will coordinate departmental compliance activity with t he Director of the YMG
and the Director of Compliance. There should be regular contact with the compliance
leaders about matters of common interest.
Each clinical department must prepare a plan to address compliance efforts on a
departmental basis. Large departments may also choose to develop plans for specific
divisions. Before becoming effective, such plans should be reviewed by the Director of
the YMG to ensure consistency with overall policies. If there are concerns about the
content of any departmental plan, the Director of the YMG should consult with the
Department Chair to explore whether the plan can be modified through mutual
agreement. If such consultations fail to resolve the concerns, the Director of the YMG
may recommend that the Dean modify the department's implementation plan.
The department (or divisional) implementation plans shall, at a minimum, include the
following features:
1. written policies and procedures for billing activity undertaken by departmental
personnel, including any specialty specific standards that may be relevant to regulatory
compliance;
2. educational and training programs to address billing issues of particular importance to
the department;
3. a program for ensuring, and documenting, that all new department personnel, including
faculty and housestaff, receive training with regard to proper billing;
4. a program for routine "spot checks" of departmental billing (or proposed billing) to
review compliance, with the results of such reviews being reported to the department's
compliance leader and to the Director of Compliance;
5. a system that tracks billing or compliance issues that have been raised within the
Department and the resolution of those issues; and
6. an annual review of the existing compliance plan in order to identify the need for
changes and to identify specific compliance objectives during the succeeding year.
Departments or Divisions should advise the Director of the YMG prior to engaging any
outside billing consultant and should provide a copy of any reports prepared by such
consultants.
Education and Training
The Director of Compliance shall be responsible for ensuring that the University policies
concerning billing are disseminated to by faculty and billing personnel. To accomplish
that objective, the Director of Compliance will work with the Director of the YMG, the
Departments, and any other individuals or entities that handle professional fee billing for
University faculty to ensure that there is a systematic and ongoing training program that
enhances and maintains awareness of billing policies among existing staff and that
introduces new personnel to University billing policies. All training materials directed to
billing issues will be submitted to the Director of Compliance for review.
All physicians and billing personnel should participate in training about billing issues and
the Director of Compliance, working in concert with the Departments, should develop a
system to document that such training has occurred. Moreover, if a concern develops
about particular billing issues, the Director of the YMG may direct that physicians and/or
billing personnel attend training sessions on particular issues. The training materials will
identify the specific people who should be contacted by physicians or billing personnel
about billing questions. It is the University's intent that every employee involved with
professional fee billing receive the equivalent of one hour training each year.
Monitoring
Under the supervision of the Director of Compliance, a sample of medical records and
corresponding bills for each department and division will be periodically reviewed for
compliance with the University's billing policies and with legal requirements. The
Director of Compliance may choose to review proposed charges that have not yet been
submitted for payment. Each department shall be reviewed at least annually, but the
Director of Compliance may require more frequent reviews. The results of such reviews
will be reported to the Director of the YMG, the audited healthcare provider and to the
department's compliance leaders. Moreover, the Director of the YMG and the COO may,
after consultation with legal counsel for the University, engage an external billing expert
to review records for a particular department or drawn from a cross-section of
departments.
If any of these reviews identify instances of possible non-compliance, the Compliance
Officer shall report that fact to the Director of the YMG, the Chair for the department
whose billings are at issue, the COO, the director of University Audit and to Office of the
General Counsel. In consultation with legal counsel, the Director of the YMGshall review
the situation to determine whether there appears to have been any activity inconsistent
with university policies.
Reporting Compliance Issues
As a general matter, questions about billing issues should be presented initially to one of
the departmental compliance leaders. But the training materials will also inform
University employees and billing personnel that they may report to the Director of the
YMG, the Director of Compliance, or to the Office of the General Counsel any activity
that they believe to be inconsistent with University policies or legal requirements
regarding billing. The materials will explain how those persons can be contacted. The
Director of Compliance should use innovative communication methods, including
computer communications, to assure that the elements of this compliance program are
well understood by affected employees.
Employees who report in good faith possible compliance issues should not be subjected
to retaliation or harassment as a result of the report. Concerns about possible retaliation
or harassment should be reported to the Director of the YMG.
The Director of Compliance will maintain a log of compliance concerns that are reported
directly to the Director of the Yale Medical Group. This log will record the issue, the
departments or divisions affected and the resolution. As concerns are reported, they will
be reported to the Director of the YMG and annually to the University's internal auditor
and the Medical Billing Compliance Committee. The log reports should note any issues
that remain open. This log should be treated as a confidential document and access
should be limited to those persons at the University who have responsibility for
compliance matters.
Confidential Hotline
The Director of Compliance will establish a telephone "Hotline" to permit compliance
issues to be reported on a confidential basis. The Hotline will be available 24 hours a day
and the Director of Compliance will ensure that training and educational materials
include information on how the Hotline can be accessed. The University shall maintain a
log reflecting any billing complaints received via the Hotline and the results of the
investigation of those complaints. All billing complaints will be investigated unless the
information provided by the Hotline contains insufficient information to permit a
meaningful investigation. In such instances, the log will explain why no investigation was
undertaken.
Investigating Compliance Issue
Whenever conduct that may be inconsistent with a billing policy or requirement is
reported to the Director of Compliance, the matter should be referred to the Director of
the YMG. If the Director of the YMG determines that there is reasonable cause to believe
that a compliance issue may exist, an inquiry into the matter will be undertaken with
appropriate assistance from the Office of the General Counsel and the University's
Internal Auditor. Responsibility for conducting the review will be decided on a case-bycase basis. The results of the inquiry will be made available to the Director of the YMG,
to the Office of the General Counsel and to the Internal Auditor. University employees
should cooperate fully with any inquiries undertaken by the Director of the YMG , the
Office of the General Counsel, the Office of the Chief Operating Officer, or the
University's Internal Auditor. To the extent practical and appropriate, efforts should be
made to maintain the confidentiality of such inquiries and the information gathered.
Nothing in this Plan shall limit the authority of the University's Internal Auditor to
conduct investigations or to act on his or her own initiative.
Corrective Action Plans
Whenever a compliance issue has been identified, through monitoring reporting of
possible issues, investigations, or otherwise, the Director of the YMG shall have the
responsibility and authority to take or direct appropriate action to address that issue. The
corrective action will be set forth in writing. In developing a corrective action plan, the
Director of the YMG should obtain advice and guidance from the University's legal
counsel. There should also be consultation with the Director of Compliance and with
appropriate clinical and billing personnel. Information about the corrective action plans
should be provided to the Dean, the Office of the Chief Operating Officer, the Office of
General Counsel and to the Internal Auditor.
Corrective action should be designed to ensure not only that the specific issue is
addressed but also that similar problems do not occur in other areas or departments.
Corrective action may require that billing be handled in a designated way, billing
responsibility be reassigned, that certain training take place, that restrictions be imposed
on billing by physicians or other health professionals, that repayment be made, or that the
matter be disclosed externally. If it appears that certain individuals have exhibited a
propensity to engage in practices that raise compliance concerns, the action plan should
identify actions that will be taken to prevent such individuals from exercising substantial
discretion with regard to billing.
Corrective action may include recommendations that impose a sanction or disciplinary
action. Moreover, if the Director of the YMG determines that any non-compliance has
been willful, the Dean should be informed of that finding. University employees who
have engaged in willful misconduct will be subject to disciplinary action, up to and
including termination in appropriate cases, in accordance with School and University
policies and procedures.
Compliance Audit
On an as needed basis, the University's Department of Internal Audit shall conduct an
audit of the University's current professional billing operation including a review of
billing policies, procedures and practices. The purpose of the audit, which should include
such probe samples as the Department of Internal Audit considers advisable, is to
ascertain whether the billing process has reasonable controls in place to assure that
providers, including Federal health insurance programs, are billed appropriately for
services rendered as claimed. A written report describing the results of the audit should
be prepared.
Annual Report
On or before July 31st, the Director of Compliance should prepare and distribute a report
describing the efforts during the preceding year. The report shall include the following
elements:
1. A summary of the general compliance activity undertaken during the preceding
financial year, including any changes made to the Compliance Plan;
2. A copy of the Hotline log for the preceding financial year;
3. A copy of the preceding financial year's Compliance Audit if such an audit was
undertaken by the Department of Internal Audit;
4. A description of actions taken to ensure the effectiveness of the training and education
efforts;
5. A summary of actions to ensure compliance with the University's policy on dealing
with excluded persons; and,
6.Recommendations for changes in the Plan that might improve the effectiveness of the
University's compliance effort
.
Revisions to this Plan
This Compliance Plan is intended to be flexible and readily adaptable to changes in
regulatory requirements and in health care systems as a whole. The Plan should be
regularly reviewed to assess whether it is working. The plan should be changed as
experience shows that certain approach is not effective or suggests a better alternative. To
facilitate appropriate revisions to the Plan, the Director of Compliance should prepare a
report, at least annually, that describes the general compliance efforts that have been
undertaken during the preceding year and that identifies any changes that might be made
to improve compliance. Circulate the annual report to the Director of the YMG, the
Department Chairs, the University's General Counsel or her designee, to the University
Internal Auditor, and to others with an interest in compliance for their comments about
possible revisions to the Plan.
1 The University intends that this compliance plan embrace all elements of an "effective
program to prevent and detect violations of law," as identified in Commentary 3(K) to
8A1.2 of the Federal Sentencing Guidelines. In addition, the plan has incorporated the
objectives and components of the Committee of Sponsoring Organizations (COSO),
Internal Control-Integrated Framework; comprising five major accounting groups.
Appendix B
Excluded Persons Policy
The University confirms the importance of compliance with 42 U.S.C. 1320a-7a(a)(6),
which imposes penalties for "arrang[ing] or contract[ing] (by employment or otherwise)
with an individual or entity that the person knows or should know is excluded from
participation in a Federal Health Care Program... for the provision of items or services for
which payment may be made under such a program." Accordingly, prior to employing or
contracting with any provider for whom the University intends to submit bills to a
Federal health care program, the University will take appropriate steps to confirm that the
provider has not been excluded. Those steps will include checking the provider's name
against the HHS/OIG Cumulative Sanctions Report and the GSA Debarred Bidders List.
The University's Compliance Officer will provide training to employees with
responsibility for personnel functions about how to access those lists. If the University
learns that a prospective provider (either as an employer or contractor) is excluded, the
University will not hire or use that provider. .
If the University learns that any of its current providers (either as employees or
contractors) has been proposed for exclusion or excluded, it will remove such providers
from any involvement in or responsibility for Federal health insurance programs until
such time that the University has confirmed that such provider is not proposed for
exclusion or excluded.
APPENDIX C
Medical Billing Compliance Committee: Membership List
Cynthia Walker
Deputy Dean for Finance and Administration
James Brink, M.D.
Chair Department of Diagnostic Radiology
Jack Elias , M.D.
Chair Department of Internal Medicine
Marianne Dess-Santoro
Executive Director of Patient Financial Services
Ronald J. Vender, M.D.
Chief Medical Officer, Yale Medical Group
Judy Harris
Director of Compliance, Yale Medical Group
David J. Leffell, M.D.
Director of the Yale Medical Group
Jonathan Tamir, M.D.
Associate Chairman for Finance and Administrator Internal Medicine
Douglas Bebbington
Director of University Internal Audit
Dorothy K. Robinson
Vice President and General Counsel, or Designee
Stephanie Spangler, M.D.
Deputy Provost for Biomedical and Health Activity
Robert Udelsman, M.D.
Chair Department of Surgery
Rev. 12/98
Rev 2/01
Rev 3/01
Rev 9/01
Rev 12/01
Rev 3/05
Rev 5/06
Rev 1/08