What Exactly is Compliance?

I keep hearing “we have to do…to be compliant…or we can’t do…because it would be a compliance issue” and a lot that I hear really doesn’t make sense to me, so I’ve done some research to try to clarify “compliance” issues.
In 1998, the OIG published Compliance Program Guidance for hospitals. That guidance was “intended to assist hospitals and their agents and subproviders…develop effective internal controls that promote adherence to applicable Federal and State law, and the program requirements of Federal, State, and private health plans.”
It goes on to say that, “The adoption and implementation of voluntary compliance programs significantly advance the prevention of fraud, abuse, and waste in these health care plans while at the same time furthering the fundamental mission of all hospitals which is to provide quality patient care to patients.”
Some of the special areas of OIG concern include:
*Billing for items or services not actually rendered
*Providing medically unnecessary services
*Upcoding
*DRG “creep”
*Outpatient services rendered in connection with inpatient stays
*Teaching physician and resident requirements for teaching hospitals
*Duplicate billing
*False cost reports
*Unbundling–specifically defined by the OIG as “the practice of submitting bills piecemeal or in fragmented fashion to maximize the reimbursement for various tests or procedures that are required to be billed together and therefore at a reduced cost.”
*Billing for discharge in lieu of transfer
*Patients freedom of choice
*Credit balances–failure to refund
*Hospital incentives that violate the anti-kickback statute or other similar Federal or State statute or regulation
*Joint ventures
*Financial arrangements between hospitals and hospital-based physicians
*Stark physician self-referral law
*Knowing failure to provide covered services or necessary care to members of a health maintenance organization
*Patient dumping
In 2005, the OIG issued “Supplemental Compliance Program Guidance for Hospitals”. In that document they state “Perhaps the single biggest risk area for hospitals is the preparation and submission of claims or other requests for payment from the Federal healthcare programs.” Further stating, “Common and long standing risks associated with claims preparation and submission include inaccurate or incorrect coding, upcoding, unbundling of services, billing for medically unnecessary services or other services not covered by the relevant healthcare program, billing for services not provided, duplicate billing, insufficient documentation, and false or fraudulent cost reports.”
Sound familiar? Does the OIG ever say that correcting a mistake–whether it’s adding a charge to the CDM for something that was not on it, or fixing an incorrect price–is a compliance issue? I don’t see that. So long as the documentation for the charge exists, it should be billed. Not billing for services provided is just as non-compliant as billing for services that aren’t documented.
In a transmittal dated March 13, 2009, CMS reiterates that “The hospital should include charges associated with medical and surgical supplies on claims so their costs are incorporated in rate setting, and payment for these supplies is packaged into the payment for the associated procedures under the OPPS in accordance with 42 CRF 419.2(b)(4).”
In the 2005 supplement, the OIG highlights other risks involving outpatient procedure coding:
*Billing on an outpatient basis for “inpatient only” procedures
*Submitting claims for medically unnecessary services
*Submitting duplicate claims or otherwise not following NCCI guidelines
*Submitting incorrect claims for ancillary services because of outdated CDM’s
*Circumventing the multiple procedure discounting rules
*Improper Evaluation and Management code selection
*Improper billing for observation services
Omega’s core business is auditing claims for accuracy and completeness of charges and rebilling the corrected claims. In addition to that service, we review payments for accuracy and completeness. We address the CDM issue that the OIG discusses by providing our Lost Charge Recovery clients with free access to our web-based CDM compliance tool. And finally, we use OCExaminer to ensure that all claims are NCCI compliant before they go out.
For compliant claims, Omega has you covered. Isn’t it time you let us check you out?

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