Objectives. On-boarding the New Provider. Successful On-Boarding: Integrating Newly Acquired Physician Practices Into Your Compliance Program

Transcription

1 Successful On-Boarding: Integrating Newly Acquired Physician Practices Into Your Compliance Program 2012 HCCA Clinical Practice Compliance Conference Session 601 1:00 p.m. 2:00 p.m. Objectives 1. Assess the new practice s compliance program infrastructure and resource needs. 2. Implement a compliance auditing and monitoring program and evaluate potential compliance risks 3. Learn strategies to overcome potential challenges during the on-boarding process. 2 On-boarding the New Provider Individual Physician Physician Network Physician Practice 3 1

2 On-boarding Challenges Practice location Different information technology EMR Billing system Corporate culture may not align with ours New level of accountability Sanctions Resistant to change We ve always done it that way and we ve never been audited They told us it would be business as usual Ownership Hospital owned Managed Separately operated network 4 On-boarding Challenges Network C Network A (Employed Providers Network B with (Owned) (Managed) Separately Owned & Operated Network) 200+ Practices 20+ Practices 2,000+ Providers 100+ Providers Subject to CHS Compliance & Privacy Program Only Providers are Subject to CHS Compliance & Privacy Program 5 The Network Compliance & Privacy Matrix Chief Compliance Officer Physician Network Administration Corporate Compliance Department Regional Directors Regional Representative Network Compliance Leadership Guides & enforces the compliance program in a practice-level oversight role Reports directly to Corporate Compliance Department Facility Compliance Advisor (FCA) Network Technical Leadership Ensures expectations of network work plan have been fulfilled at the practice level Reports to Compliance Leadership Functional Compliance Coordinator (FCC) Corporate Technical Leadership Prepares corporate work plan templates for network technical leadership Functional risk area knowledge experts & resource for network technical leadership 6 2

3 Formulating the Diagnosis History Chief complaint Chronological description of the presenting problem(s) Possible causes During the interview (history taking) the diagnosis begins to take shape Exam Observations Collection of conclusive evidence Series of considerations and exclusions Eliminate diagnoses that do not fit clinical picture Diagnosis is refined during the exam 7 Formulating the Diagnosis Decision Making Laboratory and x-ray results may further help to illuminate the diagnosis Follow up visits may be necessary to verify the diagnosis or modify as new information is obtained Once formulated, the diagnosis serves as the basis for the treatment plan When you hear hoof beats, think horses, not zebras. 8 Benefits Collect information once rather than multiple individuals asking for the same information at different times No duplicate questions Provides efficiencies in terms of time, people and compliance Collaborative approach helps build a better relationship with practice & providers Acclimate new hires to corporate culture Introduce resources early Get new hires up to speed faster Minimize risk & liability through early detection and integration of services Use checklist to collect information & manage process 9 3

4 On-boarding the New Practice The Diagnosis Process Manage the gap between your network and your new practice

5 The Diagnosis Process - History Announcement of New Practice Acquisition Initiation of New Practice Transition Distribute Compliance & Privacy Data Collection Tools On-Boarding Tool 90 Day Privacy Assessment Anti-Markup Rule Survey Reach Out to Practice Compliance/Privacy Representatives Larger size practices may have dedicated Compliance and/or Privacy Staff 13 The Diagnosis Process - Examination Assess Reponses Provided on Compliance & Privacy Tools to Identify: Resource needs Items which may pose potential risk Conduct New Provider Orientation Introduction to coding, billing & documentation requirements Provider Baseline Compliance Audits are conducted approximately 2 months following orientation 14 The Examination Tool Kit On-Boarding Tool Privacy 90 Day Assessment Anti-Markup Rule Questionnaire New Provider Orientation 15 5

6 On-Boarding Tool Comprehensive Risk Assessment Tool Excel Spreadsheet Format Distributed Approximately 1 2 Months Post Acquisition Allows for Identification of Potential Compliance & Privacy Risk to Organization 16 On-Boarding Tool Tool Consists of 5 Individual Worksheets 1 st Worksheet is for Practice Information 3 Questionnaire Worksheets Coding & Billing Claims & Denials Management Compliance & Privacy Programs 4 th Worksheet is a Document Needs List 17 On-Boarding Tool Refer to Handout 18 6

7 On-Boarding Tool Practice Information Worksheet Practice Demographics Practice Management Contacts List of Providers & Specialty/Subspecialty Provider Based or Freestanding 19 On-Boarding Tool Questionnaire Worksheets Coding & Billing Medical Records Hardcopy, EMR, Hybrid Who Assigns Codes Providers, Coders, Other Incident-to Billing, Split/Shared Billing Use of 3 rd Party Vendors for Image Over-reads 3 Day Payment Rule Claims & Denials Management Payer Mix ABN Use Non-CLIA Waived Lab Testing DME/HME 20 On-Boarding Tool Questionnaire Worksheets Compliance & Privacy Programs Frequency of Provider Audits Frequency of Compliance & Privacy Education History of Probe Audits, Office for Civil Rights Complaints Storage of Archived Records 21 7

8 On-Boarding Tool Document Needs List Compliance & Privacy Policies E/M, Procedure Code Utilization Documentation Templates Encounter Forms/Charge Tickets ABN Forms Cheat Sheets List of Vendors for Ancillary Services 22 Privacy 90 Day Assessment Tool Excel Worksheet consisting of 12 elements which align with HIPAA Privacy Rule requirements e.g. Policies & Procedures, Notice of Privacy Practices Questions are assigned to each element to test compliance with the regulatory requirement Responses to these questions are selected from a drop down menu The responses are weighted & allow for a quick Privacy gap analysis An overall compliance score is calculated & projects potential Privacy risk exposure 23 Privacy 90 Day Assessment Tool Refer to Handout 24 8

9 Anti-Markup Rule Questionnaire Simple survey tool designed to test for potential Anti-Markup Rule issues Survey questions assess: Relationships with outside vendors/suppliers for diagnostic tests or services Presence of written contracts with outside vendors/suppliers Refer to Handout Billing process for technical & professional components Substantially All test Site of Service test 25 New Provider Orientation Coding Education For Newly Employed Providers Mandatory Accredited 2.0 Category 1 CME Conducted by Sr. Compliance Specialists Agenda Items Include E/M Coding, Key Elements Teaching Physician Guidelines Incident-to & Split/Shared ICD-9 Coding Scribes Signature Requirements 26 The Diagnosis Process Decision Making Once responses to information requests are received... Assess current resource needs & then provide Education & Training Policies/Procedures Documentation Templates Encounter Forms Assess potential risk exposure & then remediate Previous & Current Audit Activity Pending/Past Repayments OCR Complaints Coding & Billing Trends Tools allow for prioritization of risks & action planning for potential violations 27 9

10 28 Baseline Provider Audits Baseline Provider Audits Conducted within days of New Provider Orientation Establishes a baseline for providers understanding of assigning procedure & diagnosis codes Providers receive individual education based upon baseline audit findings Following Baseline Audit, Provider Enters Into Established Compliance Audit Program 29 Physician Network Compliance & Privacy Work Plan Formalized auditing & monitoring Work Plan for calendar year Outlines audit requirements for 7 Risk Areas Designates audit due dates & responsible parties Findings reported quarterly to Corporate Office Benchmarked against other networks in the system Published to Administrative Oversight committees & the Governing Board Corrective actions monitored 30 10

11 Physician Network Compliance & Privacy Work Plan Identify Key Responsible Parties for Conducting Work Plan Items Hospital Owned Networks vs Separately Operated Networks Hospital personnel may be responsible for certain risk areas on Network Work Plan Compliance Program Provider Auditing & Monitoring All providers audited at least once annually Audit program includes a Phase system Provider moves through subsequent phases when audit scores consistently below 90% Individual provider education on audit findings after each audit Phase 3 - provider personally pays for education time & chart review Phase 4 - provider personally pays for 100% review of Medicare/Medicaid records 33 11

12 Compliance Program Provider Auditing & Monitoring Providers with consistent 100% audit scores can meet criteria for Provider Recognition Award This award was created to: Recognize providers who code appropriately as demonstrated by audit scores Encourage providers not to undercode services to ensure a passing compliance score. 34 What is Our Goal? A NETWORK-WIDE CULTURE OF COMPLIANCE AND ETHICS Commitment to Corporate Discipline Shared Code of Conduct Consistent Policies and Practices Open Communication 35 Contact Information Pam Rowell, RHIA, CPC, CHCO, CCEP Vice President, Corporate Compliance Carolinas Healthcare System pam.rowell@carolinashealthcare.org Laura Lyon, MHA Assistant Vice President, Corporate Compliance Carolinas Healthcare System laura.lyon@carolinashealthcare.org