Ohio State University Physician’s Inc. Compliance Program Lori Oberholzer, JD, MS, RT, (R) Jennifer Kelley, RN, BS OSU Physicians, Inc.
Objectives • OSUP Compliance policies and procedures • Discuss the compliance auditing and monitoring process • Discuss OSUP compliance education components
OSU Physicians (“OSUP”) • • • • • • • •
17 Specialties 1000+ Providers Chief Compliance Officer (physician) Sr. Compliance Director Compliance Director 10 Compliance Specialists (auditors) 1 Compliance Coordinator 475 Audits per year
Corporate Compliance Team
Compliance Oversight • Compliance Committees: – OSUP Board / Faculty Group Practice – Compliance, Governance and Ethics Committee – OSUP Operations Committee
Compliance Specialists • Each individual assigned to a specific department/division • Allows for development of in-depth and personalized knowledge • Focus training to their providers
Part I Compliance Policies and Procedures
Policies and Procedures • OSUP has Employee Standards of Conduct – Every employee should receive a copy upon employment and is responsible for knowing and understanding this information. • Employee Standards of Conduct is located on our Intranet under the Compliance tab.
Employee Standards of Conduct •
DISPLAY GOOD JUDGMENT AND HIGH ETHICAL STANDARDS – Conduct business with honesty, fairness and integrity. These qualities are demonstrated through truthfulness and respect for the laws applicable to our business. Acting with integrity is the responsibility of every employee of Ohio State University Physicians, Inc. (OSUP).
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Q: My supervisor directed me to do something that I believe is against OSUP policy and maybe the law. I don’t want to do something improper, but I’m afraid if I don’t do as I am told, I may lose my job. What should I do?
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A: Consider discussing the request with your supervisor to be sure you understand the facts and that he or she is aware of your concern. If you are uncomfortable about discussing the situation with your supervisor, or cannot resolve your concern at this level, approach your supervisor’s manager, or use the Compliance Department to determine other possible resources. Do not risk your job or the organization’s future by taking part in an improper activity. There are appropriate actions you can take. OSUP strictly prohibits retaliation against employees who raise such concerns.
Additional Compliance Policies • Vendor Policy • HIPAA Privacy and Security policies • Conflict of Interest policy • Compliance policies – Auditing and Monitoring – Corrective Action – Teaching Physician – Non-physician Practitioner – Timeliness of Documentation
Compliance Education • General training: – All OSUP employees are required to receive one hour of general compliance training each year • Exception: Coding and Billing staff – 2 hours
• New provider education: – All new providers will receive one-on-one compliance education within 5 days of employment with OSUP • All providers are required to complete at least 2 hours of compliance training annually
Compliance Education • New physician and employee orientation • One-on-one meetings • Quarterly compliance newsletters with quizzes • Computer based learning (CBL’s) • Compliance presentations at faculty or resident meetings
Part II OSUP Compliance Process
Compliance Plans • Each fiscal year (July 1 – June 20) an auditing and monitoring plan is developed specifically for each department/division • Plans are reviewed with the Administrator and Department Chair • Each plan is developed based on a culmination of the following resources/historical information: – OIG Work Plan – RAC reviews – CERT reviews – MAC issues and topics – Previous audit findings – Data analysis
Year-End Reporting • Report is generated of all the reviews • In-person meeting with administrator and physician chair • Reports are also presented to: – Compliance, Governance and Ethics Committee – OSUP Board of Directors – OSU Wexner Medical Center Compliance Committee
New Providers • All new providers receive one-one compliance education at the start of employment – Review the OSUP compliance program – Review applicable documentation guidelines – Compliance policies and procedures – E/M Pocket Guides (see example)
New Providers cont. • Discuss compliance “hot topics” – Electronic medical record documentation – Medical necessity – Timeliness of documentation – Medical Students – Non-physician Practitioners – Consultations – Discharges – Modifiers
New Providers cont. • All new providers receive a review of his/her services within 60 days of billing for services – A minimum of 20 services are reviewed • E/M • Procedures – Ensure that correct CPT codes and ICD-9 diagnosis are selected – Documentation is adequate – Feedback and education is completed at the end of the review
Annual Provider Reviews • All providers must pass at least three (3) consecutive years of annual compliance reviews • Once achieved, providers are then placed on an every other year schedule • Current passing rate is 80% (since January 2006) – FY 2013-2014 – 85% – FY 2014-2015 – 87% – FY 2015-2016 – 90% • A minimum of 20 service reviewed • Education and feedback given to provider
Example Data Comparison
Physician Education • All providers are notified of the results of their reviews • If a provider passes their review (85% or higher) – may discuss results through e-mail, phone or in-person meeting • If a provider does not pass their review (<85%) – one-on-one meeting is required
Special Project Reviews Include a sample of services over an entire division/ group, including all providers who bill for that particular service. Education is provided to all applicable providers based on the outcome of the review. o o
Teaching Physician Rules NP/PA services
o
25 modifier
o
Consultations
o
Wound care
o
Hyperbaric services
o
Infusions
o
High paying services
o
High levels of service
o
Data driven studies
o
OIG Work Plan
o
High volume rejections
o
Incident-to-Services
o
ICD-10
Faculty Education • Compliance Specialists attend faculty meetings to present information on the following – General audit findings that affect the entire group – Findings from special project reviews (ICD-10) – IHIS documentation education • Copying/pasting, copy forward or cloned notes • Use of scribes • Open encounters
– Non-Physician Practitioner (NPP) guidelines – E/M education
Quality • Two Sr. Compliance Specialists audit the Compliance Specialists once per year • Evaluation tool is shared with the staff so they have knowledge of the criteria
Total Points Possible
Compliance File Review
Data (15% of total score)
Appropriately reviewed and analyzed provider billing data and documented in Audit Rationale in MD Audit. Evidence of items considered include: OIG workplan, □RAC issues list, □FPSC data, □prior reviews, □IHIS open encounters, □past EthicsPoint complaints, and □other.
15
Audit process (5% of total score)
Were all parameters appropriately selected in MD Audit (including audit case profile and cases closed, etc.)?
2.5
Were charges reviewed and completed per Auditing and Monitoring timeliness standards? If not, was there a reason documented?
2.5
Were the CPT codes reviewed and correct?
10
Were the ICD-9 codes reviewed and correct?
10
Were modifiers reviewed and applied correctly?
10
Were the TP and NPP guidelines applied appropriately when necessary?
10
Was provider contacted regarding suggested coding changes?
4
Were approved changes completed and refund/rebill completed correctly?
4
Were the charges timely released from TES “HOLD” status?
4
Were the audit results shared with the provider, Administrator, Division Director and Chair as appropriate?
4
Did the Provider Cover Letter have correct compliance rate? And was it signed by the provider?
4
Were the final provider MD Audit reports and/or SRS correct and accurate?
4
Were the “Follow up Action” items completed and documented in MD Audit
3
Was appropriate coding and billing staff notified of audit results?
3
Coding (50% of total score)
Charge Release (10% of total score)
Provider Education (20% of total score)
Was a follow-up review scheduled within 60 days where appropriate? Audit Score
10 100
Total Points Received