3/16/2016 1 How Does Your Program Rate? Tried and True Principles of Compliance Terri L. Gilbert, Senior Manger, Aegis Compliance & Ethics Center, LLP and Lisa Taylor, Director & CCO, UC Health Welcome! Who we are: Lisa A. Taylor, JD, CCEP Director & Chief Compliance Officer UC Health 513‐585‐8043 Terri Gilbert, CPC, CHC, CPMA Senior Manager Aegis Compliance & Ethics Center, LLP 513‐646‐9202 Text Polling! Number to text: 22333 Message box: UCHPOLL (one word) Return Message: “Participating with Kristin Kreuter” And then text your poll response
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3/16/2016
1
How Does Your Program Rate?Tried and True Principles of
Compliance
Terri L. Gilbert, Senior Manger, Aegis Compliance & Ethics Center, LLP and
Lisa Taylor, Director & CCO, UC Health
Welcome! Who we are:
Lisa A. Taylor, JD, CCEPDirector & Chief Compliance OfficerUC Health513‐585‐8043
• Difference between ordering “observation” or “in‐patient” in the hospital
• The visit must span two midnights or fit an exception
• The government cares because it impacts reimbursement
• Document, Document, Document
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Sunshine Act (or Open Payments Law)
• Requirement of manufacturers of pharmaceuticals and medical devices to publically report payments to physicians and teaching hospitals.
• MLN Matters # SE1330 – June 2013
• Check the List
• Challenge the list if needed
Hospital Submitted Quality Data
• Meaningful Use – Stage 3
– EHR Incentive Programs
Meaningful Use Stage 3• For the EHR Incentive Programs in 2015 through 2017, major provisions
include:
• 10 objectives for eligible professionals including one public health reporting objective, down from 18 total objectives in prior stages.
• 9 objectives for eligible hospitals and critical access hospitals (CAHs) including one public health reporting objective, down from 20 total objectives in prior stages.
• Clinical Quality Measures (CQM) reporting for both eligible professionals (EPs) and eligible hospitals/CAHs remains as previously finalized.
• Since January 2013 Medicare has made $559 million in payments
• Physicians are required to document the medical necessity of a home visit in lieu of an office or outpatient visit
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Prolonged Services
• Reasonableness of services
• Considered to be “rare and unusual”
Concurrent Surgeries
• Two or more overlapping surgeries
• Language in the Medicare Teaching Physician Guidelines are vague – “key and critical portions”, “immediately available”, etc.
• Train, Document and Track
Mid‐Level Providers• When a hospital inpatient, outpatient or emergency department
Evaluation and Management (E/M) service is shared between a physician and a Non‐Physician Practitioner (NPP) the service may be billed under either the physician's or the NPP's UPIN/PIN number.
– Employed by same employer
– Both fully credentialed
– Both provide medically necessary face to face portion of the E/M encounter with the patient and document their participation
– Documentation must substantiate medical necessity and support the level of E/M code submitted
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STARK
• Prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or immediate family) has an ownership interest unless an exception applies
• Most often – Agreements
– More than 1 year
– FMV
– In writing
Kickback
• Knowingly and willfully offer, pay, solicit or receive any remuneration directly or indirectly to induce or reward referrals of items or services
• Beware ‐
– Below FMV
– Free
– State Law
– What you “give” to patients
ICD‐10• ICD‐10 is the 10th revision of the International Statistical Classification of
Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.
• Codes for Disease and Procedural Classifications = 16,000 Codes