Compliance Program
Third Party Billing Company
Table of Contents
INTRODUCTION .......................................................................................................... 3
Compliance Program Purpose and Objectives .......................................................... 3
Standards of Conduct and Written Policies & Procedures ........................................ 4
Standards of Conduct: ................................................................................................. 4
Risk Assessment – Coding: .......................................................................................... 4
Risk Assessment – Billing Process: ............................................................................. 4
Claim Submission Process: .......................................................................................... 5
Credit Balances:............................................................................................................ 6
Integrity of Data Systems: ........................................................................................... 6
Compliance as an Element of a Performance Plan: .................................................. 6
Designation of the Compliance Officer ........................................................................ 7
Training and Education ................................................................................................. 8
Effective Lines of Communication .............................................................................. 10
Enforcing Standards Through Well-Publicized Disciplinary Guideline ................. 11
Disciplinary Policy and Actions: ............................................................................... 11
New Employee/Hire Policy: ....................................................................................... 11
Auditing and Monitoring ............................................................................................. 12
New Employee Monitoring: ....................................................................................... 12
Periodic Monitoring: .................................................................................................. 12
Responding to Detected Offenses and Developing Corrective Actions Initiatives . 13
Miscellaneous Compliance Areas ................................................................................ 14
ACKNOWLEDGMENT OF RECEIPT................................................................... 15
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INTRODUCTION
We are dedicated to serving our clients in an ethical, legal and professional manner. The primary objective of our
compliance program is to promote ethical conduct and establish an organizational culture of compliance.
Healthcare providers rely on our services to provide timely claims submission and follow-up, as well as education on
CMS billing requirements. Federal and state laws governing claims submission continue to become more complex. Our
management team is dedicated to demonstration of high ethical standards, understanding and complying with the
applicable federal billing regulations and expects the same commitment from its employees and clients. Therefore, we
have established a Compliance Program for its officers and employees.
Our company’s compliance program outlines responsibilities of management and employees as well as its clients. A copy of our
compliance plan will be made available to all clients.
Compliance Program Purpose and Objectives
As set forth below, the focal points of our Compliance Program are as follows:
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Implement written policies, procedures and standards of conduct;
Designate a compliance officer;
Conduct effective training and education;
Develop effective lines of communication;
Enforce standards through well-publicized disciplinary guidelines;
Conduct internal monitoring and auditing; and
Respond promptly to detected offenses and developing corrective action.
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1
Element
Standards of Conduct and Written Policies & Procedures
Standards of Conduct:
A Code of Conduct has been developed and provided to each existing employees. Thereafter, new employees will
receive a copy of the Code of Conduct. Our organization’s Code of Conduct includes the following:
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Act in accordance with all federal, state and local laws, rules and regulations;
Support an environment that promotes a high-quality of care;
Commit to maintaining accurate books and records;
Understand that all employees are representatives of the organization (to our clients, the employees are
the organization);
Act in accordance with high ethical standards when dealing with competitors; and
Create an environment conducive to lawful and ethical treatment of stakeholders, both internal and
external.
Before enrolling a potential client, we will check the Office of Inspector General’s (OIG) Cumulative Sanction Report on
the Internet at http://exclusions.oig.hhs.gov/ & Medi-Cal’s website for “Suspended and Ineligible Provider List”. If a
potential client has been sanctioned, we will not enter into an agreement for billing.
Risk Assessment – Coding:
Our company’s policies and procedures for coding include the following guidelines:
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Coding and billing should be based on medical record documentation;
Any changes to the medical documentation should be made by the provider of service;
Inquiries or questions in regards to coding for patients should be addressed to the provider of service either
directly or indirectly through the biller assigned to that client;
If the coder finds a physician’s documentation to be unclear or conflicting, the provider should be asked for
clarification;
Coded claims that are rejected pertaining to diagnosis and procedure codes should be brought to the coder’s
attention for feedback and/or correction;
All medical, financial and other personal information will be kept confidential; and
Coders will be required to provide current coding certification and, in case of an independent
contractor, have a signed “HIPAA Business Associate Agreement” on file.
Risk Assessment – Billing Process:
We will monitor and audit the risk areas that OIG has identified as problematic:
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Risk Areas
Billing for items or services not
actually documented on the
superbill
Unbundling
Upcoding
Inappropriate balance billing
Inadequate resolutions of
overpayment
Duplicate billing in an attempt to
gain duplicate payment
Description
Action Plan
Audit all charge tickets against
internal audit reports.
Unbundling occurs when a billing
entity uses a separate billing code for
service that have an aggregate billing
code.
Upcoding reflects the practice of
using a billing code that provides a
higher reimbursement rate than the
billing code that actually reflects the
service furnished to the patient.
Inappropriate balance billing refers
to the practice of billing patients for
the difference between what a
provider charges and the disallowed
amount.
An overpayment is an improper or
excessive payment made to a health
care provider.
Duplicate billing occurs when the
billing company submits more than
one claims for the same service or
the bill is submitted to more than
one primary payor at the same time.
Failure to properly use modifiers
Routine waiver of copayments
and billing third-party insurance
only
Routine waivers are write-offs of
dues owed to the provider. These
violate the anti-kickback statute.
Discounts and professional
courtesy
Discounts and professional courtesy
may not be appropriate unless the
total fee is discounted or reduced. In
such situations, the payor (e.g.,
Medicare, Medicaid, or any other
private payor) should receive its
proportional share of the discount or
reduction.
If the codes provided by the provider
of service are unbundled, inform the
client.
Bill services as provided by the
provider of service.
Balance bill patients as indicated on
the EOB.
Upon determination of an
overpayment, provide reports or forms
to the client for refund.
 Monitor the frequency of claim
submission to avoid duplicate
billing.
 Confirm patient eligibility to submit
to the appropriate payor.
Only use modifiers prescribed by the
provider.
Our company should encourage
providers to make a good faith effort
to collect copayments, deductibles and
non-covered services from patients.
Our company should encourage
providers to make a good faith effort
to collect all patient dues.
Claim Submission Process:
Our company’s policies and procedures for claims submission include the following guidelines:
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Complete, proper, timely, and legible paperwork such as superbill and patient registration information are
obtained prior to billing to ensure that only accurate and properly documented services are billed;
Compensation to our company for billing services does not provide any financial incentive to improperly upcode
claims;
Process for pre- and post-submission review of claims to ensure claims submitted for reimbursement accurately
represent the CPT-4 and ICD-9 codes provided by the clients to us;
Communicate with the provider when documentation is confusing and lacking; and
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Resources such as the internet, medical billing books/manuals, and training are available to correctly interpret
medical diagnosis. In addition, the provider of service will be contacted for clarification and feedback.
Credit Balances:
Credit balances occur when payments, allowances or charge reversals posted to an account exceed the charges billed.
Our policies and procedures for credit balances are as follows:
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Record all payments in the patient’s accounts;
Print a transaction report on a monthly basis for all overpayments (note: overpayments should be indicated by a
negative or credit balance on the report);
Print a “Refund Request” letter for each account and send to our clients for specific patients; and
Send the report/letter to the client to process the refund.
Integrity of Data Systems:
Our organization is committed to have:
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Regular viable backup system in place;
Up-to-date virus definitions and scans; and
Protection against unauthorized access to its computer system.
Compliance as an Element of a Performance Plan:
Our company’s Compliance Program will be a factor in its employees’ performance evaluation.
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2
Element
Designation of the Compliance Officer
The compliance officer is _______________ [name of the compliance officer].
The compliance officer’s primary responsibilities include:
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Oversight: oversee and implement the Compliance Program;
Reporting: on a regular basis, report to the CEO on the progress of implementation of the Compliance Program;
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Revise: revise the program in light of changes in the organization's needs and in the laws and policies of the
government and other payers;
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Acknowledgement/certification of receipt: review employees’ certifications that they have received, read and
understood the standards of conduct;
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Education and Training: develop, coordinate and participate in educational and training program related to the
Compliance Program;
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Internal Investigation: independently investigate and act on matters related to compliance;
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3
Element
Training and Education
Basic training and education will be provided on an ongoing and as needed basis to our employees, in the following
areas:
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Specific government and private payer reimbursement principles;
Prohibitions of making payment for referrals;
Anti-kickback statutes;
Prohibitions for self referrals;
Correct use of provider identification numbers;
Correct coding and billing practices, including proper translation of narrative diagnosis to ICD-9 codes, and
prohibition on determining or altering a CPT-4 code;
Submitting a claim for a physician when rendered by a non-physician (i.e., the "incident to" rule and the
physician physical presence requirement);
Proper documentation of services rendered;
Signing forms for a physician related to claims;
Medicare as a secondary payer and other coordination of benefits issues;
Overpayment/credit balance reporting;
Rules about waiver of deductibles and co-payments;
Reassignment issues;
Appropriate use of modifiers;
Correct coding initiative edits;
Unbundling;
Rules about balance billing/discount policies;
Confidentiality of client and its records;
Duty and method in which to report misconduct;
The importance of maintaining the integrity of computer data and respecting established security parameters;
Workers Compensation billing.
Additionally, we will disseminate the compliance message via internal correspondence which will include:
 The topics listed above;
 Risk areas published in OIG Special Fraud Alerts (available at
http://oig.hhs.gov/fraud/fraudalerts.html);
 Areas identified during on-going audits of Remittance Advice or risk analysis; and
 Materials distributed by the Medicare and Medicaid carriers and other payers.
All employees are required to have a minimum of 1-3 hours annually for basic training in compliance areas.
Copies of the correspondence and documentation of the regular training will be kept in a folder labeled “Compliance
Education” by the Compliance Officer.
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We will provide necessary resources, in hard copy or electronic format, such as current CPT-4, ICD-9 and HCPCS
books, Medical Terminology, various medical billing books/manual and payor manuals/newsletters to staff. In
addition, the Internet has training modules available at:
http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=1
If questions arise, the officers of our company can research topics on the Internet at various sites, including:
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http://www.cms.hhs.gov/ (Centers for Medicare and Medicaid Services)
http://www.hhs.gov/ (United States Department of Health and Human Services)
http://oig.hhs.gov/publications/workplan.html (OIG Workplan)
http://answers.hhs.gov/cgi-bin/hhs.cfg/php/enduser/std_alp.php (HHS FAQ)
Our organization has adopted OIG’s recommendation for attendance and participation at training programs to be a
condition of continued employment. Failure to comply with the training requirements will result in disciplinary
action, including possible termination when such failure is serious.
In addition, clients will be informed or educated and encouraged to:
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Implement and maintain an effective health care compliance program that complies with OIG Compliance
Guidelines;
Ensure compliance with proper documentation and medical necessity requirements for federal and state
programs;
Refrain from submitting false, inaccurate or improper documentation relating to financial and medical
records;
Conduct periodic internal compliance audits.
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4
Element
Effective Lines of Communication
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While open communication is encouraged, employees may report violations of compliance policies
anonymously, in writing to the compliance officer.
The compliance officer will maintain a log of these reports, including the nature of the investigation and its
results. This log will be maintained for seven (7) years.
Confidentiality of the reporting employee's identity will be maintained.
An employee will never be subjected to retaliation due to truthful reporting of a violation.
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5
Element
Enforcing Standards Through Well-Publicized
Disciplinary Guideline
Disciplinary Policy and Actions:
Managers and employees of our company who fail to comply with the standards of conduct, policies and procedures,
federal, state, or private health care program requirements, or those who have otherwise engaged in wrongdoing, have
the potential to impair the company's status as a reliable, honest and trustworthy organization. Therefore, violations of
the compliance plan will be treated seriously and will result in one or more of the following actions by management,
based on the seriousness of the offense:
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Verbal and written warning with documentation in the personnel file;
Final warning with probation;
Termination of employment;
Referral for criminal prosecution or civil action.
Performance evaluations will include an assessment of the employee's known adherence to compliance principles.
New Employee/Hire Policy:
Our employees must conduct themselves in an ethical manner, therefore:
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Potential new employees will be subjected to a reference check.
The application of employment will require the applicant to disclose any criminal conviction, as defined
by 42 U.S.C. 1320 a-7 (i).
Before hire, we will check the OIG’s website at http://exclusions.oig.hhs.gov/ to ascertain if a federal
program has sanctioned the candidate.
We will not hire anyone who has been excluded from federal and state programs.
If an employee has known pending criminal charges or proposed exclusion, the employee will be
removed from direct responsibility for billing or following up on claims to federal or state health care
programs.
We will not engage the services of independent contractors or agencies that have been excluded from
federal and state health care programs.
All new employees will be provided with a copy of the compliance program that outlines the expected
code of conduct.
New employees must understand that compliance is a condition of employment.
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Element
Auditing and Monitoring
The officers of our company or their designee shall conduct regular and random audits to ensure adherence to applicable
federal and state laws, our compliance program, to take appropriate steps to respond to detected offenses through
corrective actions, repayments and referrals to governmental agencies, as appropriate, and to report credible evidence of
misconduct by our company to the provider, as necessary.
New Employee Monitoring:
We will ensure that each new employee understands the essential elements of the job functions by:
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Reviewing claim-related work prior to submission for two (2) weeks following placement in the role, or
until the supervisor or the designee is confident of compliance.
The employee will complete a competency test. The passing grade is seventy five (75%) percent. The test
must be retained in the employee's personnel file.
Periodic Monitoring:
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Evaluation of billing practices:
 Claims will be audited against charge tickets to ensure accuracy of data entry.
 Provide regular “Production Report” to clients and to request feedback on their review of the
accuracy on their submitted CPTs and ICD-9.
 Provide annual trend analysis that show deviations–positive or negative. For example, frequency
and percentiles of CPT and HCPCS codes as well as claim rejection by code which will demonstrate
E&M coding practices.
 EOBs will be monitored to determine reasons for claims denial or down coding of claims.
Corrective action and education to billers and clients will be initiated, as needed.
 Regular evaluation of billing complaints.
Provide post-training testing of staff on their comprehension of the material. A passing grade is seventy five
(75%) percent. The test should be retained in the employee's personnel file.
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7
Element
Responding to Detected Offenses and Developing
Corrective Actions Initiatives
The medical provider is responsible for accurate CPT-4 and ICD-9 coding based on documentation in the patient's
medical record. If we determine that the provider's documentation or information has resulted in a compliance issue,
specific education will be offered. Additionally, we will make recommendations for corrective action, in writing. If a
provider demonstrates a pattern of non-compliance, we will:
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Within thirty (30) days, notify the health care provider of the issue and rationale for the determination of an
improper claim;
Refrain from submitting any false or inappropriate claims;
Terminate the contract, in the absence of corrective action.
If we discover credible evidence of misconduct by its employee(s), it will cease the misconduct and report the evidence
to the appropriate agency, within thirty (30) days. If the misconduct is related to inadvertent errors, we will correct and
report the problem to the appropriate designated payor.
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Miscellaneous Compliance Areas
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Overpayments: Our company will notify the provider of credit balances as it encounters such cases. The
provider will be asked to return overpayments in a timely manner.
Record Retention: Computer files will be retained for a period of seven (7) years. The medical provider will be
contractually obligated to retain medical records and original billing data.
Provider Payments: Our company will have no access to withdraw from any medical provider's bank accounts.
All payments are deposited directly into our clients’ bank accounts.
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ACKNOWLEDGMENT OF RECEIPT
I have received a copy of our Compliance Program and Code of Conduct. I am committed to adhering to the
principles outlined in the program and policies and procedures of our company.
I will report violations/possible violations to the officers of our company, either verbally or anonymously in writing.
_______________________________________________
Name
_______________________________________________
Signature
_______________________
Signature Date
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