GENERAL REIMBURSEMENT AND BILLING PROCEDURES

Transcription

1 GENERAL REIMBURSEMENT AND BILLING PROCEDURES SCOPE: All AMR HoldCo, Inc. and its subsidiaries (the Company ) colleagues. For purposes of this policy, all references to colleague or colleagues include temporary, part-time and full-time employees, independent contractors, clinicians, officers and directors. PURPOSE: To ensure general reimbursement and billing procedures. POLICY: I. INTRODUCTION A. AMR is committed to ensuring that its billing practices comply with all contractual arrangements it may have with payors as well as with all federal and state laws, regulations, guidelines, and policies including, but not limited to Medicare and Medicaid. B. AMR is committed to developing and maintaining policies and procedures that ensure accurate billing and submission of claims for services only when medically necessary and when appropriate goods and/or services actually are provided. C. As billing procedures are governed by complex laws and regulations and as improper billing practices could result in significant liability, this Corporate Policy on Reimbursement and Billing Procedures (the Policy ) sets forth specific billing procedures with which all billing, reimbursement and claims processing personnel ( Billing Personnel ) must comply as a condition of employment. Managers and supervisors are expected to promote and explain this Policy to all Billing Personnel. Violations of this Policy will result in disciplinary action up to and including discharge from employment. II. BRIEF OVERVIEW OF THE LAWS THAT REGULATE BILLING PROCEDURES Page 1 of 10

2 A. Federal law sets forth criminal and civil penalties for knowingly or willfully making or causing to be made a false statement of any material fact in any application for payment, or for use in determining the right to such a payment from a federal health care program (such as the Medicare, Medicaid or TriCare programs). Therefore, AMR and individual employees can be held criminally and civilly liable for submitting a false claim and for engaging in any activity that causes a false claim to be submitted. B. Examples of the types of activities that could violate federal false billing laws include: 1. Filing a claim for goods or services that were not provided or were not provided as described on the claim form; 2. Filing a claim for services without documentation to substantiate the performance of those services; 3. Submitting a claim containing information known to be false; 4. Misusing Social Security or Medicare symbols, emblems or names in Medicare marketing; 5. Providing wheelchair services but billing for ambulance services; 6. Providing services in a BLS ambulance but billing for ALS or otherwise billing for a higher level of service than appropriate. (See AMR Compliance Policy on Level of Service Billing, Policy No for further clarification); 7. Adding false diagnoses; 8. Using past diagnosis to represent the patient s current condition; 9. Routinely billing Medicare patients at rates higher than private patients; 10. Listing incorrect conditions for the patient, such as bed confined when the patient was not bed confined; Page 2 of 10

3 11. Billing using the wrong address for the AMR site that rendered the service, so as to obtain higher reimbursement rates in another locality; 12. Falsifying the origin or the destination; 13. Using incorrect modifiers; 14. Billing for waiting time when there was no waiting time; 15. Billing for excess mileage; 16. Billing for unloaded mileage; III. DIVISION BILLING AUDITS 17. Billing for and accepting reimbursement for services which were not medically necessary; and 18. Billing Medicare as primary when it should be secondary under applicable Medicare Secondary Payer rules. A. Each AMR Patient Business Service (PBS) Center and the third party billing agent will maintain a Quality Assurance (QA) Program to ensure that all billing policies and procedures contained in this policy are adhered to on an ongoing basis. B. Management of each AMR PBS Center and the third party billing agent shall designate a QA Representative to perform internal QA reviews. This employee should have proven knowledge of health care rules and regulations, as they apply to Medicare, and must remain current on all changes relating to reimbursement from third party payors. C. In addition to the QA reviews of regular employees, reviews of a similar nature should be performed on all new and/or temporary employees for a specified period of time determined by the training guidelines set forth by AMR PBS and the third party billing agent. D. The results of QA reviews shall be retained in accordance with the AMR Page 3 of 10

4 Compliance Policy on Records Management, Policy No E. Billing personnel will be informed of the on-going audit process and the identity of the employee performing the audits. F. When problems are revealed through the QA process the appropriate PBS Manager must be notified for immediate resolution of the problem through employee counseling, training, or other corrective action. In addition, Compliance must be notified of any systemic issues. G. The designated QA person shall assist PBS management and third party billing agent designee with the following: 1. Ensuring that all billing manuals are up to date and archived appropriately. In this regard it is AMR s policy that no outdated government and carrier reimbursement and billing manuals be discarded. Instead, separate chronological binders will be retained. 2. Ensuring that government policies and procedures are reviewed regularly in order to verify that all billing policies reflect any changes. 3. Ensuring that policies are in place which require proper documentation for billed services prior to billing payors. IV. TRAINING OF BILLING PERSONNEL A. All Billing Personnel are required to attend a training session semi-annually, which is devoted specifically to issues involving claims processing and submission, billing, coding, medical necessity, and reimbursement matters. The Respective Management Team is responsible for this training session and shall work jointly with AMR s Ethics & Compliance Department to develop and organize training sessions. In addition, the training sessions will provide a summary of legal sanctions for improper billings. This training shall provide for not less than two (2) hours of formal instruction. All new Billing Personnel will participate in a training session specific to billing policies and procedures prior to assuming independent billing responsibilities. B. At the conclusion of each training session Billing Personnel will be required to Page 4 of 10

5 certify, in writing, that they have received and understand the training regarding billing policies and procedures. They must also indicate whether they are aware of any non-compliance. V. BILLING OF REIMBURSEMENT DISCREPANCIES A. Billing Personnel may encounter uncertainties as to whether particular health care services are covered, or the appropriate manner in which to claim reimbursement for services, including the selection of appropriate procedure and/or modifier codes for claims submission purposes. 1. In such circumstances, Billing Personnel first shall bring the issue to the attention of their supervisor. If uncertainty still exists, the supervisor shall discuss the issue with the appropriate Billing Manager and QA, and Ethics and Compliance Department, when necessary. 2. If the uncertainty still continues, the Ethics & Compliance Department will work with the respective Management Team to contact the payor, Medicaid administrator, or Medicare Carrier by telephone, with written follow up, in attempt to resolve the issue. B. When the designated person contacts the carrier or payor regarding policy issues that affect multiple patients or claims, the designated person shall follow up with written communication to memorialize the telephone discussion. A copy of the written communication should be presented to the appropriate PBS management who will provide training for Billing Personnel. Copies of all written communication with carrier/payor representatives shall be retained in the Billing Department and provided to the Ethics & Compliance Department as appropriate. The employee designated to contact the carrier/payor shall bring to the attention of their immediate supervisor promptly any situation in which sufficient information cannot be obtained from the carrier or payor to clarify the issue. C. When it is necessary for Billing Personnel to contact the carrier/payor regarding the ordinary resolution of the processing of an individual claim, each contact must be documented in the internal computer billing system, and should include, at a minimum, the following: Page 5 of 10

6 1. The name of the party; 2. The department of the party contacted; 3. The date and time of the contact; 4. The telephone number of the party contacted; 5. The question asked of the party and the answers the party gave in response to those questions; and 6. The resulting billing actions taken. D. The designated employee shall report immediately to his or her supervisors any billing instructions received from carriers or payors, either verbally or in writing, that are inconsistent with current AMR billing policies or procedures or previous guidance from the same carrier or payor. Billing supervisors shall bring such reports promptly to the attention of the Ethics and Compliance Department for immediate review. VI. OTHER BILLING ISSUES A. Medical Documentation In addition to documentation contained in the Patient Care Report ( PCR ), medical information may be obtained by Billing Personnel through supplemental documentation (i.e. discharge summaries) included with the PCR or through telephone research. When Billing Personnel collect medical information by telephone from a patient, physician, or facility, they shall complete a Telephone Medical Documentation Form (See Approved Compliance Form). In completing this form, the Billing Personnel who contact the outside source should document: 1. The name of the patient; 2. Date of Service; 3. The name of the facility, if applicable; Page 6 of 10

7 4. The name of the party contacted; 5. The department of the party contacted; 6. The date and time of the contact; 7. The telephone number of the party contacted, and 8. The questions asked of the party and the answers the party gave in response to those questions. Billing system notes shall indicate that a call was made and the appropriate form was completed. B. Patient Complaints As AMR is committed to providing high quality services to its customers and responding to customer needs and concerns, it is important that AMR keep track of all complaints that are voiced by customers, either by phone, by mail, or in person. In this regard, any complaint received by Billing Personnel must be brought to the attention of the designated Management Team member in accordance with the local SOP. All complaints from external government entities must be forwarded to the Ethics and Compliance Department. VII. CLAIMS SUBMISSION PROCEDURES AMR is committed to ensuring that all claims submitted are accurate and correctly identify the goods and services provided. A. Determinations of Medical Necessity 1. AMR is committed to ensuring that claims submitted to third party payors are for services that AMR believes are medically necessary. 2. In an effort to ensure that patients transported by ambulance meet medical necessity requirements, AMR shall assist its customers/sources of patient referrals in understanding requirements governing medical Page 7 of 10

8 necessity. a. AMR is committed to providing education to customers (e.g., physicians, social workers, etc.) regarding their role in the accurate submission of claims for services furnished to patients from AMR. b. The Ethics & Compliance Department will provide guidance to management regarding education for customers. B. Physician Certification Statement See AMR Compliance Policy on Determination of Medical Necessity, Policy 50400, for information on Physician Certification Statements. C. Repetitive Patients See AMR Compliance Policy on Repetitive Patients, Policy D. Assignment of Benefits and Waiver of Liability See AMR's Corporate Policy on Obtaining Patient Signatures No , for information on patient signatures and assignment of benefits and waivers of liability. VIII. MEDICARE PROVIDER NUMBERS Medicare Provider number and enrollment applications (CMS form 855) and billing shall be consistent with local carrier regulations. Medicare rules require that the information on the 855 be updated with any changes within ninety (90) days, unless it pertains to a change of ownership which is required within thirty (30) days. Questions regarding this issue should be directed to the Enrollment Department. IX. WAIVER OF CO-INSURANCE AND DEDUCTIBLE ISSUES See AMR Compliance Policy on Waivers of Co-Insurance and Deductibles, Policy X. MEDICARE PART B APPEAL PROCESS A. Federal regulations set forth an appeal process for Medicare beneficiaries to Page 8 of 10

9 XI. REFUNDS follow in appealing a determination by a Medicare carrier. Furthermore, these regulations extend to physicians or any other provider of Part B services the same right to appeal a Carrier's determination. Thus, AMR may appeal determinations made on claims by Medicare Carriers in accordance with these federal regulations. B. If an attorney, either within AMR or outside AMR, conducts an appeal, that attorney becomes responsible for all contacts with and submissions to the Carrier from that point forward. Billing Personnel should consult the Ethics & Compliance Department or the attorney before contacting the carrier. A. When government, third party and/or private payments are received in error, or a credit balance is posted due to a duplicate payment by multiple sources, immediate steps shall be taken to ensure that the payment refund request is completed and forwarded to Corporate Accounting in accordance with the Carrier, Agency or local standard operating procedure. Processing of Medicare and Medicaid refunds may not exceed more than 60 days from date of discovery. B. Each Billing Center shall assign refund approval authority to at least one manager or director level employee. C. With respect to overpayments that cannot be refunded, AMR shall comply with applicable Unclaimed Property Laws in the applicable state(s). XII. DISCIPLINARY ACTION A. This Policy on Reimbursement and Billing establishes the general policies and procedures with which all Billing Personnel must comply as a condition of employment with AMR. This Policy is designed to ensure that each employee's conduct conforms to the highest ethical standards and is in accordance with all applicable laws, rules and regulations. Any doubts or questions whatsoever as to the propriety of a particular situation, whether or not the situation is described within this Policy, should be addressed either to your immediate supervisor or to one of AMR's Ethics & Compliance Personnel. B. Every Billing Department employee of AMR is required to understand and comply fully with the rules established by this Policy. The standards of conduct Page 9 of 10

10 that govern AMR's relationship with the government are applicable to all of AMR's employees whether or not the employee is directly engaged in performing activities relevant to any federal, state or private contracts. Decisions regarding requests for interpretation of or exceptions to this Code of Conduct may be made only by the Ethics & Compliance Department. C. Any Billing Department employee violating any provision of this Policy will be subject to disciplinary action, up to and including discharge from employment. In addition, promotion of and adherence to this Policy and to the Corporate Ethics & Compliance Program will be one criteria used in evaluating the performance of supervisors, managers, directors and officers. See AMR Compliance Policy on Reporting of Potential Issues or Areas of Noncompliance, Policy for more detail. XIII. OTHER POLICIES In addition to policies referenced above, you may wish to consult the following policy for more information regarding billing: A. See AMR Compliance Policy for Billing Personnel, Policy Page 10 of 10