Corporate Compliance

       

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Table of Contents

Background of Corporate Compliance Programs in Health Care

Commitment to Corporate Compliance

Compliance Officer and Educational Activities

Auditing and Monitoring

Communication

Internal Investigation, Response to Problems and Corrective Action Initiatives

Background of Corporate Compliance Programs in Health Care

      Medicare is the country's largest health insurance program. In general it covers individuals over the age of 65 who are not working for an employer that provides insurance coverage, some disabled patients, and individuals with end stage renal disease. All in all nearly 40 million individuals receive at least some of their health insurance through this program. A description of the Medicare program for consumers is at http://www.medicare.gov/basics/overview.asp

    Medicaid is a state run  health insurance program for certain low-income and needy people. It covers approximately 36 million individuals including children, the aged, blind, and/or disabled, and people who are eligible to receive federally assisted income maintenance payments. It is financed by both state and federal sources. A description of the Medicaid program for consumers is at http://www.hcfa.gov/medicaid/mcaicnsm.htm.

    Spending for both of these programs is large, and increases exceed the rate of inflation. In an endeavor to keep growth at a sustainable rate, one government initiative is to aggressively combat fraud and abuse in health care.  Conflict of interest issues and provider billing are undergoing particular scrutiny.  When a physician or hospital sends in a bill to a governmental or a private insurer, the health care provider describes what problem the patient had and what services were rendered by using a series of alphanumeric codes.  The implied understanding between provider and payer is that the coding is accurate and the services were proper for the patients' level of illness.  Routinely when the bill is submitted payment is made, and  to a great extent it is an honor system.    This arrangement breaks down if the insurance company does not timely pay the approved amount for covered, appropriate services, or if the health care provider engages in fraud or abuse in billing.

    There are a few blatantly unscrupulous providers who knowingly bill for fictitious visits or procedures.  Obviously these entities need to be shut down and prosecuted.  A few providers very aggressively bill for services. This is not fraudulent in the strict definition of the word,  however they are abusing the system. The vast majority of health care providers endeavor to submit accurate and appropriate bills and certainly the preponderance of invoices are in this category.   When a coding error occurs it is most likely not because of fraud or abuse but due to a legitimate error in a complex coding system. Coding is not always straightforward and sometimes even expert chart abstractors disagree. 

    It is in the interest of all legitimate health care providers to combat fraud and abuse, and to insure that their billing is accurate and appropriate.  In an endeavor to help insure this for our practice Dr. Elliott has set up the following corporate compliance program. If you have any concerns about our policies or a question regarding a specific bill please review the following and contact us.  All inquiries will be expeditiously and fairly evaluated. Errors will be corrected.

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Commitment to Corporate Compliance

    Dr. Elliott and his staff are committed to the principals as described in the AMA Principles of Medical Ethics As part of these standards is the requirement physician's respect the law and provide appropriate patient care.  An intrinsic part of these values is a commitment to appropriate chart documentation and billing practices. Specifically, up coding, over coding or any other abusive practices will not be tolerated.

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Compliance Officer and Educational Activities

    Our office has a staff of three employees, and all are committed to this policy. Dr. Elliott as owner of the business has the authority to set the organizational practices, and institute any necessary changes. He is currently designated as the compliance officer.  The compliance officer has and will continue to participate in educational activities with respect to ethical medical principles in general, and HCFA fraud and abuse policies in particular.

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Auditing and Monitoring 

        Claim development submission is the responsibility of Dr. Elliott. This individual will assign the appropriate CPT4  and ICD9 codes.  Any returned claims because of coding questions will be reviewed by him and appropriate appeals or corrections made. The following is the standard for our medical records:

 

bulletThe medical record should be complete and legible.

bulletThe documentation for each patient encounter should include: the date and reason for the encounter, H & P history findings, relevant negative observations, the results of germane, prior diagnostic test results; assessment, diagnosis; plan for care,  and signature of the individual making the entry. If the patient is referred from another physician there should be documentation of a return letter or telephone call.

bulletIf not documented, the rationale for ordering diagnostic and other ancillary services should be intrinsically obvious from the chart review.   Relevant past and present diagnoses should be accessible to the treating and/or consulting physician. When necessary for ongoing care records from other physicians should be requested.

bulletAppropriate health risk factors should be identified.  The patient's progress, response to and changes in treatment, and revision in diagnosis should be documented.

bulletCPT4 and ICD9 codes must be supported by the above.

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Communication

    All employees are aware of  this corporate compliance plan and effective communication is a two way street.  If you have a concern contact Jody Watson, Susan Cudzilo or Dr. Elliott and we will respond.   There is also a specific data entry field on the From you... page where you may e-mail Dr. Elliott with any concerns or questions.  Confidentiality will be maintained, and no retaliation will be tolerated against individuals making a complaint.

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Internal Investigation, Response to Problems and Corrective Action Initiatives


        Dr. Elliott has been in practice for over 25 years and all billing questions or concerns are always investigated.  Most of them were resolved in his favor when additional information was provided.  In the rare instances of an error, refunds were made and this occurs at the most once or twice a year. 

    If an error in billing is found by virtue of an internal audit or because of a received concern appropriate refunds will be made.  A review of similar cases will be done to determine if the event is isolated or more generalized.    Any appropriate refunds will be made, and system changes instituted to prevent a recurrence. If Dr. Elliott requires outside help in reaching a decision the Delaware Medical Society Physician's Advocacy Office will be consulted.

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This page was last updated on 07/30/16