Thomas Jefferson University Counsel

Compliance > Frequently Asked Questions

Frequently Asked Questions

Why do we need a compliance program?

Reimbursement
What is the reimbursement compliance program?
Why do we need a reimbursement compliance program for payers other than Medicare and Medicaid?
Why shouldn’t I undercode all my services just to be safe?
Why do I need to update my encounter forms annually?
What is the difference between a new and established patient?
How do Physicians Assistants (PA) and Nurse Practitioners (NP) bill for services they perform in an outpatient setting?
Can a PA or NP see new patients?
What levels of Evaluation and Management Services can a NP or PA bill?
What is “Incident-to” billing?
How do we establish that the services provided incident-to were properly supervised?
If the physician who initiated treatment for a patient is not in the office suite on the day the patient returns for a visit, can the PA/NP see that patient even though the physician is not available to provide direct supervision?
In that scenario, where the supervising physician is different from the treating physician, how should the claim be billed?
What is a Consultation?
What is the difference between a consultation and a new patient visit?
How do I document that I provided a consult?
Can physician ask another physician of the same specialty in the same group practice for a consult?
What is an Advanced Beneficiary Notice (ABN) and when do I need to use one?
What documentation is required when performing procedures?
When auditing Evaluation and Management services, what area or areas do you find that the physicians overlook the most?
For coding purposes, are there any special documentation requirements when Concurrent care is provided?

HIPAA
What is HIPAA?
What are the goals of HIPAA?
To whom do the HIPAA regulations apply?
When must I comply by?
Are there any penalties for non-compliance?
How should I begin to prepare to comply with the HIPAA regulations?
Where can I find more information on HIPAA?
What is a Business Associate?
What are some examples of Business Associates?
What is my department required to do about Business Associates?
What should the contract contain?

General Research
Did TJU sign an agreement with the government regarding it’s research programs?
Is the agreement related to being designated an exceptional organization by NIH?
How will TJU have the exceptional organization status removed?
Will employees be required to attend additional education?
What are the regulations governing grants management on federally-funded projects?

Why do we need a compliance program?

On March 3, 1997, the Office of the Inspector General of the United States Department of Health and Human Services ("HHS OIG") released an open letter to health care providers (http://www.os.dhhs.gov/progorg/oig/modcomp/ltrhcp.html ) stressing the OIG's renewed focus on eliminating fraud and abuse in the health care arena. The letter notes the increasing popularity of compliance programs as a tool for combating fraud and abuse and hints that the existence of such a compliance policy would be considered by the OIG as a "reasonable effort" by management to comply with existing laws. Such a determination by the HHS OIG could have a substantial effect on the level of sanctions, penalties or exclusions which it imposes on a provider which is found to have violated the fraud and abuse laws.

Reimbursement

What is the reimbursement compliance program?

The goal of a reimbursement compliance program is to eliminate the coding and billing errors that will reduce the risk of a charge of fraud, to create a more accurate accounts receivable (A/R), to provide a resource for office staff to alert them to potential problems in billing and to identify system problems that can be changed through physician and staff education.

Why do we need a reimbursement compliance program for payers other than Medicare and Medicaid?

Physician offices must adhere to the coding and billing guidelines as
defined by the Center for Medicare and Medicaid Services (formerly HCFA) for all government payors. However, claims to commercial insurance carriers are frequently not handled as precisely. The passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) has brought to our attention the need to assure that the billing process from physician offices and clinics adheres to correct coding and billing standards for all third party claims.
The failure to bill correctly and the failure to provide appropriate documentation can result in significant penalties to the physicians involved as well as the individuals within the organization who have any knowledge of potential fraudulent coding and billing activities.

Why shouldn’t I undercode all my services just to be safe?

With all the talk about fraud and abuse, some physicians decide to play it safe and undercode their Medicare patient visits. Undercoding is a problem for every medical practice because it decreases earned revenue and establishes false utilization patterns. Utilization patterns are closely scrutinized by the government and by many payors. Most coding experts believe all inaccurate coding is bad coding. In some cases, undercoding can flag a physician as an outlier and lead to an investigation.
The first step to a health practice is to understand the guidelines. Many physicians undercode because of their lack of knowledge of the system. Learning to code should be an important part of every physician’s knowledge base.

Why do I need to update my encounter forms annually?

Encounter forms or superbills are a tool that is supposed to help make the documentation and coding process easier for physicians. Formatted with current procedural terminology codes according to specialty, encounter forms, also known as charge tickets or superbills, allow providers to record the diagnoses and services performed simply by checking off the matching codes on the form. But these forms also put providers at risk for reimbursement problems and billing fraud. Common errors include obsolete codes, incorrect codes, incorrect descriptors, missing modifiers, mistyped codes, and missing codes.
If a provider is unaware that the forms contain errors, they might end up choosing incorrect codes. Or they might end up selecting a code that is “closest” to the diagnosis or procedure that they performed. Choosing a code that is “closest” to the service performed is not correct coding and can land a practice in serious trouble.
Therefore, TJU has developed a policy that all encounter forms are to be updated annually, with the Central Business Office and Corporate Compliance assisting in the process.

What is the difference between a new and established patient?

AMA’s definition of a new patient is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group with in the past three years. On the flip side, an established patient is one who has received professional services from the physician, or another physician who belongs to the same group practice within the past three years.

HFCA Transmittal 1690, released on January 5, 2001, added further clarification that if no evaluation and management is rendered prior to the visit, the patient may continue to be treated as a new patient. This clarification is important because problems have occurred when billing new patient visit if the providers have rendered a non-face-to-face service for that patient within the past three years. An example is when a physician bills for an X-ray interpretation and sees the same patient two months (within 3 years) later for an office visit. This visit can still be billed as a new patient office visit.

How do Physicians Assistants (PA) and Nurse Practitioners (NP) bill for services they perform in an outpatient setting?

A PA or NP can bill either of two ways. They can bill “incident to” a physician’s service (under the physician’s UPIN) or they may bill under their own billing number.

For more information on billing for Non-Physician Practitioners, please see the Seminars Section of this Website

Can a PA or NP see new patients?

Yes, but only when they are billing under their own provider number. The rules for “incident-to” services require that a physician perform the initial service for patients being billed under the physican’s provider number.

What levels of Evaluation and Management Services can a NP or PA bill?

A PA/NP can use all code levels when they are billing under their own provider number. If billing “incident-to”, they may only used established patient codes.

What is “Incident-to” billing?

“Incident-to” billing is any billing that is provided incidental to the physician’s services by the physician’s employee. In order to bill services incident-to, the patient must be an established patient of the physician or the physician’s group practice. *******

How do we establish that the services provided incident-to were properly supervised?

TJU policy requires that the supervising provider sign the encounter form to indicate that he or she was available and providing supervision that day. (see Policy **)

If the physician who initiated treatment for a patient is not in the office suite on the day the patient returns for a visit, can the PA/NP see that patient even though the physician is not available to provide direct supervision?

If the physician who initiated the treatment is not available, it is acceptable for that patient to be seen by the PA/NP as long as there is another physician from the same group practice able to provide the required level of supervision.

In that scenario, where the supervising physician is different from the treating physician, how should the claim be billed?

The claim should go out under the provider number of the physician who supervised the service.

What is a Consultation?

A consultation is a service provided by a physician whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician or other appropriate source. A consultant may initiate diagnostic or therapeutic services. The request for the consult must be documented in the patient’s medical record. The consultant’s opinion and any services that were performed or ordered must also be documented in the record and communicated to the requestor.

What is the difference between a consultation and a new patient visit?

If the requesting physician is asking for a transfer of the complete care of the patient, then the visit should be coded as a new patient visit and not a consultation. “Complete” care is defined as the total care of the patient.

How do I document that I provided a consult?

The following must be documented for every consult:
a. The request and need for the consultation
b. The consultant’s opinion as well as any services ordered/performed.
c. The results of the consultation must be reported to the requesting physician and a copy maintained in the patient’s medical record.

Can physician ask another physician of the same specialty in the same group practice for a consult?

Yes, it is appropriate to report a consultation code when a consultative service between the same specialty in the same group practice is performed. Remember, however, that medical necessity and requirements for a consultative service must be met.

What is an Advanced Beneficiary Notice (ABN) and when do I need to use one?

An ABN is a written notice that a provider or suppliers gives to a Medicare beneficiary before Part B services are furnished when the provider or supplier believes that Medicare will not pay for some or all of the services. If the provider/supplier expects payment to be denied by Medicare, the provider or supplier must advise the beneficiary before services are rendered that , in its opinion, the beneficiary will be personally and fully responsible for payment. To be “personally and fully responsible for payment” means that the beneficiary will be liable to make payment out of pocket, through other insurance or through Medicaid or other federal or non-federal payment source. The provider or supplier must issue notices each time and as soon as it makes the assessment that Medicare payment will not be made.

What documentation is required when performing procedures?

A complete technical detail of the procedure is important not only for patient care but for reporting accurate CPT codes. A complete technical detail of the procedure should include the following:

1. Pre-operative evaluation
2. Medical necessity
3. Separate note for the procedure
4. Complete procedure note itself
5. Signed and dated by the MD

When auditing Evaluation and Management services, what area or areas do you find that the physicians overlook the most?

When auditing charts for Evaluation and Management services, it is our opinion that the majority of errors occur in the documentation of Review of Systems and Past, Family and Social Histories. This is especially true when our physician is thinking of reporting higher level of services (levels 4 and 5) for Consultations and New Patient Visits. This particular problem is not limited to certain specialties. It occurs all across the board. Savvy physicians are able to understand the requirements and have utilized patient intake sheets, questions sheets filled out by ancillary staff, or even a simple check off list in their template to meet the documentation requirements. It must be evident however, that the physician acknowledges the intake sheets or question sheets filled out by the patient or ancillary staff. This can be done by referencing to it and/or by signing and dating it.

If the physician has indeed taken 10 or more systems, Medicare allows the physician to mention the pertinent positives and negatives and using the phrase “all others are negative” instead of enumerating that each and everyone of the systems are essentially negative.

For coding purposes, are there any special documentation requirements when Concurrent care is provided?

Concurrent care is the provision of similar services (eg, hospital visits) to the same patient by more than one physician on the same day. CPT manual does not cite any special reporting requirements when concurrent care is provided. However, when concurrent care is provided, the ICD-9 diagnosis code reported by each physician should reflect the need for the provision of similar services to the same patient by more than one physician on the same day. In other words, medical necessity of why concurrent care is needed should be evidenced by the ICD-9 codes reported. It must be noted that reporting the same ICD-9 code(s) that is most specific in representing the service does not, in any means, preclude billing for the concurrent care.

HIPAA

What is HIPAA?

· HIPAA is an acronym that stands for the Health Insurance Portability & Accountability Act of 1996, Public Law 104-191.
· HIPAA is also known as the Kennedy-Kassebaum Act.
· More specifically to healthcare providers and payer, Title II, Subtitle F of HIPAA, Administrative Simplification, is intended to reduce the overall health care administrative cost.

· What are the goals of HIPAA?
· To ensure and maintain the privacy of patient health information; past, present and in the future.
· To ensure and maintain the security of electronic health information.
· To standardize electronic formats of patient health, financial and administrative information.
· To create unique health identifiers for employers, providers and health plans.

· To whom do the HIPAA regulations apply?

· The rule applies to:
· Healthcare Providers that transmit patient health information in any form (i.e., electronic or paper). Healthcare Providers are defined as a provider of services, a provider of medical or health services and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.
· Health plans (with a few exceptions that includes Workers’ Compensation) Health plans are defined as an individual or group plan that provides, or pays the cost of, medical care.
· Healthcare Clearinghouses are defined as a public or private entity, including a billing service, repricing company, community health management information system or community health information system, and “value-added” networks and switches, that either processes or facilitates the processing of health information or receives a standard transaction from another entity and processes or facilitates health information

When must I comply by?

There are three parts of the Administrative Simplifications with three different compliance dates.
Electronic Transactions and Codes Sets compliance date: October 16, 2002
Privacy compliance date: April 14, 2003
Security compliance date: Final Rule has not yet been determined

Are there any penalties for non-compliance?

Civil Monetary Penalties for failure to comply are:
$100 per incident, up to $25,000 per person, per year, per standard
Federal Criminal Penalties for intentional violations are:
Up to $50,000 plus 1 year in prison for obtaining and disclosing
Up to $100,000 plus 5 years in prison for obtaining and disclosing under false pretenses
Up to $250,000 plus up to 10 years in prison for obtaining with the intent to sell, transfer or use for commercial advantage, personal gain or malicious harm.

How should I begin to prepare to comply with the HIPAA regulations?

Contact your Corporate Compliance Officer for assistance in establishing administrative, technical and physical safeguards in order to achieve maximum protection of patient health information for unauthorized access or users.
TJU and JUP Corporate Compliance & Privacy Officer can be reached at the following location:

Robin Brown-Stovall, MBA, RHIA, CPC
Privacy Officer & Assistant Corporate Compliance Officer - Reimbursement
1020 Walnut Street
Suite 621 Scott Building
Philadelphia, PA 19107
215-503-2769

Where can I find more information on HIPAA?

http://aspe.os.dhhs.gov/admnsimp/
www.hhs.gov

What is a Business Associate?

A Business Associate is an individual or entity that assists in the performance of any activity or function that involves protected health information (PHI).

What are some examples of Business Associates?

To name a few...
coding review vendors; answering services, an outside firm used to copy or store charts; billing & practice management software vendors; outside legal services; record copying service vendors; temporary staffing agencies; transcription vendors; consulting entities; etc.

What is my department required to do about Business Associates?

In order to comply with the Business Associates requirements, your department must:
1. Identify all individuals and entities that perform services for your department, which involves protected health information (PHI).
2. Create/Amend contracts with the outside individuals/entities.

What should the contract contain?

HIPAA requires specific language to be incorporated into all Business Associates contracts. Therefore, I recommend you call our University Counsel HIPAA specialist first!

General Research

Did TJU sign an agreement with the government regarding it’s research programs?

Yes, in May 2000 TJU signed both a Settlement Agreement and an Institutional Integrity Agreement with the Federal government for a period of three years. In return for signing the agreements, TJU was released from all civil and administrative claims.

Is the agreement related to being designated an exceptional organization by NIH?

The events that resulted in the designation of exceptional organization by NIH precipitated an investigation into our grant management practices by the government. After four years of negotiation, TJU signed the Agreement and paid the Federal government $2.6 million dollars. Written into the Agreement are the procedures for removal of the designation by NIH.

How will TJU have the exceptional organization status removed?

NIH gave TJU a corrective action plan in the form of Standards and Benchmarks. TJU will submit all policies and procedures, educational materials, the Code of Conduct, effort certification procedures, and other related materials to NIH for review. After completion of the review, NIH will perform a compliance site visit at TJU. In addition to reviewing transactions and the effort system, they will be conducting interviews of staff.

Will employees be required to attend additional education?

The Institutional Integrity Agreement stipulates that TJU provide both General and Specific training sessions on an annual basis for the term of the agreement. In addition, training sessions are held monthly for new employees.

What are the regulations governing grants management on federally-funded projects?

· NIH Grants Policy Statement -
Intended to give policy guidance that serves as the terms and conditions of NIH awards
Available at: http://www.nih.gov

· Office of Management and Budget (OMB) Circulars
Available at: http://www.whitehouse.gov/OMB/grants/#circulars

· A-21 Cost Principles for Educational Institutions -
establishes principles for determining costs applicable to grants, contracts, and other agreements with educational institutions
· A-110 Administrative Requirements for Grants and Other Agreements with Institutions of Higher Education, Hospitals and Other Non-Profit Organizations -
sets forth standards for obtaining consistency and uniformity among Federal agencies in the administration of grants to and agreements with institutions of high education, hospital, and other non-profit organizations
· A-133 Audits of States, Local Governments and Non-profit Organizations -
sets forth standards for obtaining consistency and uniformity among Federal agencies for the audit of state and local governments, and non-profit organizations expending Federal awards

Content Maintained by the Webmaster
Copyright © Thomas Jefferson University. All Rights Reserved.

The Thomas Jefferson University web site, its contents and programs, is provided for informational and educational purposes only and is not intended as medical advice nor is it intended to create any physician-patient relationship. Please remember that this information should not substitute for a visit or a consultation with a health care provider. The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Health System or staff. Please read our Privacy Statement.

Thomas Jefferson University | Jefferson Medical College | Jefferson College of Graduate Studies | Jefferson College of Health Professions | Jefferson Pulse