2nd Edition
Compliance for Coding, Billing & Reimbursement A Systematic Approach to Developing a Comprehensive Program
While the vast majority of providers never intend to commit fraud or file false claims, complex procedures, changing regulations, and evolving technology make it nearly impossible to avoid billing errors. For example, if you play by HIPAA’s rules, a physician is a provider; however, Medicare requires that the same physician must be referred to as a supplier. Even more troubling is the need to alter claims to meet specific requirements that may conflict with national standards. Far from being a benign issue, differing guidelines can lead to false claims with financial and even criminal implications.
Compliance for Coding, Billing & Reimbursement, Second Edition: A Systematic Approach to Developing a Comprehensive Program provides an organized way to deal with the complex coding, billing, and reimbursement (CBR) processes that seem to force providers to choose between being paid and being compliant. Fully revised to account for recent changes and evolving terminology, this unique and accessible resource covers statutorily based programs and contract-based relationships, as well as ways to efficiently handle those situations that do not involve formal relationships.
Based on 25 years of direct client consultation and drawing on teaching techniques developed in highly successful workshops, Duane Abbey offers a logical approach to CBR compliance. Designed to facilitate efficient reimbursements that don’t run afoul of laws and regulations, this resource –
- Addresses the seven key elements promulgated by the OIG for any compliance program
- Discusses numerous types of compliance issues for all type of healthcare providers
- Offers access to online resources that provide continually updated information
- Cuts through the morass of terminology and acronyms with a comprehensive glossary
- Includes downloadable resources packed with regulations and information
In addition to offering salient information illustrated by case studies, Dr, Abbey provides healthcare providers and administrators, as well as consultants and attorneys, with the mindset and attitude required to meet this very real challenge with savvy, humor, and perseverance.
Introduction
Overview
Three levels of CBR compliance concerns
CBR compliance program development
Systematic approach
Systems theory
CBR policies, procedures, and infrastructure
Preparing for external audits
Information resources
Conducting research
Healthcare computer billing systems
CBR compliance officer and team development
Terminology, definitions, and acronyms
Case study listing
Overview of healthcare compliance
Healthcare industry
Health care payment systems
Cost-based systems
Prospective payment systems
Capitated systems
Healthcare delivery systems
Healthcare compliance laws, rules, and regulations
Statutory requirements
Contractual requirements
HIPAA
BBA
MMA
DRA
Compliance concerns and program development
Key elements for compliance programs
Compliance program areas
Use of systems approach
Settlement agreements
Structuring CBR compliance programs
CBR and seven key elements
Compliance standards and procedures
Coding policies and procedures
Billing policies and procedures
Chargemaster policies and procedures
Documentation policies and procedures
Utilization review policies and procedures
Compliance and auditing policies and procedures
Oversight responsibilities
Delegation of authority
Employee training
Monitoring and auditing
Enforcement and discipline
Response and prevention
CBR compliance officer
Use of investigative and review teams
Development of policies and procedures
Facilitation and organizational development
CBR and administrative decision making
Coding, billing, and reimbursement: Problem/opportunity areas
Identifying problem/opportunity areas
Determining real problem
Medical necessity
False claims
Service area concerns
Observation status
Emergency department
Subacute care
Non-physician providers
Medicare
fraud, abuse, and anti-kickback laws
Chargemaster concerns
Accurate information
Correlation of information
Chargeable, separately chargeable, billable, and separately billable items
Categorization of items
Charge explosion
Coding interface
Drugs and self-administrable drugs
Non-covered items and services
Special payment system requirements
Charging interface
APG and APC considerations
OIG resources
Cost reports
Organizational structuring
Notes
Comparison of organizational structures
Operational considerations
Coding and payment system demands
Procedure coding
Diagnosis coding
Revenue codes
Payment systems
Safe harbors
Statistical and benchmark utilization
Investigation and problem solving
Systems approach
Problem/opportunity identification
Problem/opportunity analysis
External solution design
Internal solution design
Solution development
Solution implementation
Solution monitoring and remediation
Graphic tools
Multiple perspectives
Raised perspective
Designing audits
Fact gathering and interviewing techniques
Team approach
Information analysis
Root cause analysis
Statistical basics and graphic representation
Data and relative data arrays
Frequency distribution
Percentages, percentiles, and proportions
Measures of central tendency
Index numbers
Graphic examples
Probability and distributions
Sample sizes and confidence intervals
Business process reengineering
Quality improvement
Benchmarking
Development of CBR policies and procedures
Developing and writing policies and procedures
Form, format, and organization of policies and procedures
Indexing and numbering
Dates
Approval process
Distribution list
Cross-referenced policies and procedures
Notes and discussion
Meta data
Areas of concern
Developing CBR compliance manuals
Special publishing of policies and procedures
Summary and conclusion
Implementing changes
Introduction
Analyzing change impact
Designing implementation plan
Pre-implementation preparation
Implementation
Post-implementation monitoring
Facilitation and organizational buy-in
Computer technology
Project planning skills and software
Consultants
Organization information flows
Developing effective training
Learning modalities
Training techniques and modes of delivery
Technology
Lecture–recitation
Developing training materials
Developing and assessing training for specific audiences
Logistics
Training at different levels and in different languages
Training trainers
Learning objectives
Tips for effective training
Team teaching
Preparation
Interpersonal communications
Audiovisual aids
Facilitating learning
Addressing resistance
Prerequisites for participants
Unlearning
Coordinating internal and external training
Recordkeeping
Monitoring and corrective action
Designing reviews and audits
Review design
Audit design
Determining sample size
Selecting samples
RAT-STATS program of OIG
Example service area considerations
Home health services
Emergency department
Observation services
Medical clinics
Inpatient services
Administrative area considerations
Assessing personnel competencies
Additional monitoring interfaces
Corrective actions
Documenting review and audit activities
Conducting CBR baseline audits
Baseline audit: Overall objective
Beginning baseline audit process
Designing baseline audits: Different approaches
Designing baseline audits: Top-down approach
Area overview
Designing baseline audits: Bottom-up approach
Hybrid approach
Tools, techniques, and processes
Utilizing payment system classification
Diagnosis-related groups (DRGs)
Ambulatory payment classifications (APCs)
Related disciplines
Integrating CBR compliance into corporate compliance
Corporate compliance programs
Seven fundamental principles
Compliance standards and procedures
Oversight responsibility
Delegation of authority
Employee training
Monitoring and auditing
Enforcement and discipline
Response and prevention
Specialized compliance programs
Whistle blowers
Managed care: Capitation compliance
CBR compliance officer
Chargemaster
Revenue enhancement
Reimbursement contracts
Service area interfaces
Cost reports
New and expanded service areas
Documentation systems
Integrating CBR compliance with other compliance programs
Documenting compliance activities and keeping records
Record retention
Investigation and subpoena response planning
HIPAA compliance
HIPAA privacy
HIPAA transaction standard/standard code set rule
Standard code sets
Revenue codes
Condition codes
Place of service codes
Standard transaction formats
HIPAA security
HIPAA National Provider Identifiers (NPIs)
Summary and conclusions
Special regulatory areas
Introduction
Provider-based rule (PBR)
Billing privileges
Emergency Medical Treatment and Labor Act (EMTALA)
Emergency department levels
Advance beneficiary notices (ABNs)
Leaves against medical advice
Non-emergency care
Non-physician providers (NPPs)
Stark law issues
Compliance considerations for hospitals
Chargemaster
Static file
Dynamic process
Charging and charge development
Special Medicare
hospital designations
Medical staff organization and credentialing
Managed care contracts
Associated entities
Medical clinics: Free-standing versus provider-based
Rural health clinics (RHCs) and federally qualified health centers (FQHCs)
Ambulatory surgical centers (ASCs)
Home health agencies (HHAs)
Independent diagnostic testing facilities (IDTFs)
Comprehensive outpatient rehabilitation facilities (CORFs)
Special hospital programs and provider-based clinics
Compliance considerations for physicians and clinics
Clinic organizational structuring
Physician relationships
Physician ownership
Non-physician providers (NPPs)
Coding documentation guidelines
Establishing medical necessity
Claims development: CPT, modifiers, and ICD
Reciprocal and locum tenens physicians
Medical staff bylaw considerations
Medical directorships
Hospital-based clinic profitability
Special compliance audits and reviews
Emergency department (ED)
E/M coding and billing
Surgical coding and billing
Modifiers
Correlation of physician and hospital coding
Medical necessity
Cardiovascular interventional radiology
Technical component E/M coding
DRG and inpatient audits
Standard DRG audits
Inpatient audits
APC audits
CPT/HCPCS coding
Modifier utilization
Special situations and special service areas
Chargemaster audits
Provider-based rule (PBR) reviews
General provider-based compliance
Provider-based clinics
Billing privileges: CMS-reviews
References and bibliography
Healthcare compliance organizations
Healthcare-related certifications
Healthcare compliance
Managed care contracting
Training and education
Facilitation, teams, and team development
Six Sigma and other quality programs
Mind mapping, creative thinking, and related subjects
Facilitation and interpersonal communications
Auditing, statistics, and related subjects
Internet, intranet, and related subjects
Health Insurance Portability and Accountability Act (HIPAA)
Chargemaster information
Acronyms
Appendices
Abbey & Abbey, Consultants, Inc (AACI) websites
Accompanying CD and CBR compliance research
CBR compliance officer
CBR compliance checklist
Sample size determination
Index
Each chapter begins with an Introduction and concludes with a Summary and Conclusions
Biography
Abbey, Duane C.
