If there is any question whether the Medical Center may bill for a particular service, either on behalf of a provider or on its own behalf, the question should be directed to the Compliance Officer for review. Medical Center employees should not submit claims for other entities or claims prepared by other entities, including outside consultants, without approval from the Compliance Officer.
Special care should be taken in reviewing these claims, and Medical Center personnel should request documentation from outside entities if necessary to verify the accuracy of the claims. The person as well as the Medical Center may be excluded from participating in the Medicare and Medicaid programs.
Numerous other federal laws prohibit false statements or inadequate disclosure to the government and mandate exclusion from Medicare and Medicaid programs. It is illegal to make any false statement to the federal government, including statements on Medicare and Medicaid claim forms.
It is illegal to use the U. Any agreement between two or more people to submit false claims may be prosecuted as a conspiracy to defraud the government. The Medical Center promotes full compliance with each of the relevant laws by maintaining a strict policy of ethics, integrity, and accuracy in all its financial dealings.
Each employee and professional, including outside consultants, who is involved in submitting charges, preparing claims, billing, and documenting services is expected to maintain the highest standards of personal, professional, and institutional responsibility. Every employee in this institution has the responsibility not only to comply with the laws and regulations but to ensure that others do, as well. Employees must report non-compliance to their supervisors, the Compliance Officer or the Compliance Integrity Hot Line.
Calls may be made anonymously, although the University encourages employees to provide their name and telephone number so that reports may be more effectively investigated. Employees uncertain about whether some conduct constitutes non-compliance should contact the Integrity Hot Line. Every attempt will be made to preserve the confidentiality of reports of non-compliance and, with regard to those reports made anonymously, the caller's name cannot be identified.
All employees must understand, however, that circumstances may arise in which it is necessary or appropriate to disclose information. In such cases disclosures will be on a "need to know" basis only. Each employee must cooperate with such investigations and may be disciplined for failing to do so. The report will be the basis for the Compliance Officer's plan or recommendation of corrective action or discipline.
Reports will be retained for six years. It is the policy of the Medical Center that no person shall retaliate, in any form, against a person who reports in good faith an act or suspected act of non-compliance although employees may be disciplined for making intentionally false reports of non-compliance. Any person who is found to have retaliated for such a report in violation of this policy shall be subject to discipline.
In addition, the Federal False Claims Act and the New York State Labor Law provide certain protections to individuals who are discharged, demoted, suspended or threatened, harassed or discriminated against by their employer in retaliation for assisting in the investigation, initiation or prosecution of a False Claims Act violation or which constitutes health care fraud under the New York State Penal Law.
The protections may include reinstatement, return of lost back pay plus interest. Demand more documentation from providers who submit claims.
Coders are key components of the healthcare revenue cycle. Compliant coding streamlines the revenue cycle, reduces claim disputes and denials, and ensures adherence to governmental healthcare regulations.
Compliant coding is important in every step of the revenue cycle. Here are some coding best practices for optimizing reimbursements and revenue:. Improve clinical documentation quality. Use technology to improve documentation and coding. HCPCS codes. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies DMEPOS when used outside a physician's office.
Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT-4 codes, the level II HCPCS codes were established for submitting claims for these items. Modifier codes. Certain modifiers indicate that a service or procedure that was performed has been altered in some manner. Utilizing the above coding systems, the UCSD Health is committed to submitting only compliant bills for professional fee services; and further, strives to provide reasonable assurance concerning compliance with conditions of payment and encounter data reporting under managed care plans.
Refunds and Fines As is current practice, amounts identified as a result of inaccurate billing are to be reported and returned as soon as possible — and no later than 60 days from the date that an over-payment is identified through a reasonable and diligence period has concluded. Payment for Attending Physician Services in Teaching Settings Medicare pays for services furnished in teaching settings if the services are: Personally furnished by a physician who is not a resident; or Furnished by a resident when a teaching physician is physically present during the critical or key portions of the service; or Furnished by a resident under a primary care exception within an approved Graduate Medical Education GME Program.
Modifier GC indicates services provided in part by a resident under the direction of a teaching physician. When the GC modifier is included on a claim, you or another appropriate billing provider certify that you complied with these requirements.
Modifier GE. If you meet the requirements for primary care exception billing, append modifier GE to each eligible service code CPT code. For DGME and IME payment purposes, a resident means an intern, resident, or fellow who is formally accepted, enrolled, and participating in an approved medical residency program.
These services may not be billed or paid under the Medicare PFS. Services Furnished by a Student. A student is an individual who participates in an accredited educational program for example, medical school that is not an approved GME Program and who is not considered an intern or resident.
Medicare does not pay for any services furnished by these individuals. When a patient is re-admitted for subsequent hospital care or for established patient visits, the teaching physician's personal note must highlight at least two of the following three components: 1 relevant history; 2 major findings of physical examination; 3 medical decision-making assessment, impression, diagnosis, or plan of care. When the teaching physician is performing services with a resident s , the teaching physician may document brief summary comments that tie into each resident's entry, which either confirm or revise each KEY element of the service s provided.
Anesthesia Services Furnished in Teaching Settings. Effective January 1, , Medicare pays for the following procedures if the teaching anesthesiologist is involved in: Training the resident in a single anesthesia case; Two concurrent anesthesia cases involving residents; or Single anesthesia case involving a resident that is concurrent to another case paid under medical direction rules. The following requirements must be met to qualify for a teaching physician payment: The teaching anesthesiologist or different anesthesiologist s in the same anesthesia group must be present during all critical or key portions of the anesthesia service or procedure; and The teaching anesthesiologist or another anesthesiologist must be immediately available to provide anesthesia services during the entire procedure.
Submit teaching anesthesiologist claims using the following modifiers: Modifier AA: Anesthesia services performed personally by attending anesthesiologist; or Modifier GC: This service has been performed in part by a resident under the medical direction of a teaching anesthesiologist.
Diagnostic Tests. The teaching physician shall either personally perform or review test results or materials and agree with or make changes and additions to the resident's interpretation. Examples of unacceptable billing practices include, but are not limited to:. If you believe any unacceptable billing practices have occurred or have any billing compliance concerns, you should discuss the issue with your supervisor.
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