Operationalizing “Compliance”

1. Operationalizing “Compliance” Anthony Guerrero, M.D. Associate Professor of Psychiatry and Pediatrics Vice-Chair for Education and Training, Psychiatry

2. Objectives • To give a practical overview of things commonly associated with regulatory “compliance”: billing and coding compliance, STARK, EMTALA, perhaps other fancy acronyms. • To outline basic resources and generic steps in creating a voluntary compliance program. • Assumption: basic orientation to compliance relevant to residency training; this presentation will focus on what you may need to expect after residency.

3. Personal message • We want you to be successful in whatever practice you choose. • We want to help you stay out of unintended trouble. • We want you to feel comfortable taking care of public-sector patients and patients on governmentally sponsored insurance plans.

4. Billing and coding compliance HIPAA STARK EMTALA CFR 42 Relates to assessment and stabilization of patients Relates to privacy Relates to substance abuse treatment Relates to accurate documentation and preventing erroneous/fraudulent claims Relates to anti-kickback rules Say what? Let’s play “matching”: Answers: 1. D. 2. B. 3. E. 4. A. 5. C.

5. Case Scenarios • In preparation for private practice, which you plan to start right after graduation, you run through a checklist of all the things you need to take care of. Did you make sure to include things like “compliance” and “HIPAA?”

6. Case Scenarios • You are interviewed for an appealing job at an agency that recently came under a “corporate integrity agreement.” You wonder what this means, and what the implications are for your practice with them.

7. Why should I bother? • Can anyone tell me?

8. Remember that quality is the driver of patient care processes • Nearly every other industry – e.g., airline industry, etc. – has rules to follow. • Error reduction is a key principle: reduces waste, improves quality

9. Individual/small group practices • Let’s start off with the DHHS/OIG guidelines for compliance programs… • http://oig.hhs.gov/authorities/docs/physician.pdf • Probably one of the most important websites you’ll ever encounter! • Wonderful examples of fraud, and everything you’d ever want to know about penalties! • A voluntary compliance program is MUCH better than an involuntary one

10. Main principles • Claims submitted to federal health care programs • Private payor claims may also be covered by a compliance plan

11. Main principles • Internal monitoring and auditing • Written standards and procedures • Compliance officer or contacts • Training and education • Responding appropriately to possible violations • Open lines of communication for education and monitoring • Well-publicized disciplinary standards

12. Component 1: Internal monitoring and auditing • Accurate billing and coding • Accurate documentation • Consider templates • Know your references • Reasonable-ness and necessity of services • Absence of incentives for unnecessary services

13. Component 1: Internal monitoring and auditing • The OIG recommends that claims/services that were submitted and paid during the initial three months after the education and training program be examined • Periodic audits should be conducted at least once per year • 5+ medical records per federal payor; 5-10 per physician • Action plan (e.g., repayment, correction of processes, training, etc.) for problems uncovered

14. Quick quiz: can anyone define for me… • 90801 • 90805 • 90807 • 90846 • 90847 • 90862

15. Quick quiz: • How exactly do insurance companies know what services you provided and for what? • What pieces of information do they need to know, and how do they get that information?

16. Component 2: Standards and Procedures • Keep these in a binder! • Having policies and procedures will save you! • Can cross-reference AMA ethics guidelines • “Risk areas” to cover: • Coding and billing • Reasonable and necessary services • Documentation (including reasons for services, location of services) • Improper inducements, kickbacks, and self-referrals

17. Practical examples • If I saw a patient for 2 hours of psychotherapy (I couldn’t help it, they kept talking), can I bill them for 2 visits on 2 separate days, since I did the work? • If I spent 30 minutes talking to a patient over the phone (once again, I couldn’t help it), and then calling in a prescription to the pharmacy, can I bill for a medication management or psychotherapy visit? • Can I waive someone’s co-pay? They’re having a difficult time right now and under a lot of emotional distress.

18. Practical examples • I’m interested in a primary care liaison model. A group of internists wants to lease me office space at a good rate. Is there anything I need to be careful of? • I’m a combined primary care/psychiatry graduate. Can I have a combined primary care/psychiatry practice and refer patients to myself?

19. Practical examples • I’m planning to work in a public-sector clinic where senior residents rotate. I was told that I only need to sign their notes. Is that true? • I’m on-call for the psychiatry ED service. What does this mean in terms of whom I am obligated to treat? • I’m interested in making a lot of money. What do I need to be careful of if I start a “walk in” psychiatry clinic?

20. Component 3: Compliance Officer • Overseeing implementation and insuring the up-to-dated-ness of the compliance program • Coordinating periodic audits • Coordinating training • Checking OIG’s black-list • Investigating problems and insuring corrective action

21. Component 4: Training and Education • Compliance in general: rules and penalties • Coding and billing • CPT • ICD-9 • Should have at least annual training • Document any training activity; remember your binder!

22. Component 5: Responding to possible violations • Overpayment issues • Individual correction • Systems correction • Possibility of criminal violations • Know your resources

23. Component 6: Open lines of communication • People shouldn’t be intimidated from doing what’s necessary to insure regulatory compliance • Exchange of information

24. Component 7: Disciplinary standards • Should be a part of initial and ongoing orientation • Main theme is accountability

25. Generic steps that could benefit any patient care process • Key ingredients: • Sound philosophy (quality, efficiency) • Policies and procedures • Forms to insure that things are done uniformly and painlessly • Quality improvement principles (plan, do, check, act; monitoring and correction; mechanism to continuously update) • Administrative structure; people • Education and training and accountability • Ever wonder how the airline industry does it?

26. Similar processes with HIPAA compliance • Policies and procedures, based on HIPAA laws, for anything involved in transaction of information • Forms (privacy practices, consent forms) to insure that things are done uniformly and painlessly • Quality improvement principles (plan, do, check, act; monitoring and correction; mechanism to continuously update) • Administrative structure; people (privacy officer) • Education and training and accountability

27. Relevant to psychiatry • Can refer to frequently asked questions about HIPAA: http://www.hhs.gov/ocr/hipaa/ • CFR 42 is very important! • PART 2--CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS: http://www.access.gpo.gov/nara/cfr/waisidx_03/42cfr2_03.html

28. Technology: the wave of the future • Computerized, customizable packages for HIPAA compliance • Useful websites are posted on our very own DOP website: http://dop.hawaii.edu

29. Thank you for your attention!Good luck! Anthony Guerrero, M.D. GuerreroA@dop.hawaii.edu