Sample Professional Fee Billing Compliance Plan

Foreword

_______representatives collaborated to develop a Compliance Plan which describes the commitment and procedures for proper billing of physician services.

The Compliance Plan was reviewed by the following:

• _____Operations Committee
• Hospital Operations Team
• College of Medicine Clinical Administrators
• Legal Counsel

The Compliance Plan was approved by _____ Board of Directors, April 29, 1997, and by _____, Dean of the College of Medicine.

Table of Contents

Chapter 1: Introduction

Chapter 2: Chief Compliance Officer (CCO)

Chapter 3: Policy Guidelines

Chapter 4: Departmental Implementation Plans

Chapter 5: Education and Training

Chapter 6: Monitoring

Chapter 7: Reporting Compliance Issues

Chapter 8: Investigating Compliance Issues

Chapter 9: Corrective Action Plans

Chapter 10: Revisions to this Plan

Closing Statement

Chapter 1 -- Introduction

_____ have been and continue to be committed to conducting professional fee billing in accordance with applicable regulations. For this purpose, professional fee billing includes the following: proper selection of diagnostic coding, category of service and level of service; documentation of clinical services; submission of claims; patient billing; collection; payment posting; error correction; and retention of records for physician professional services.

Compliance with laws applicable to professional fee billing is challenging because the regulatory requirements governing reimbursement for professional services are complex and changing. To underscore and enhance the commitment of _____ and to better assist faculty physicians, residents, other healthcare providers and appropriate clinical/billing staff in this area, _____ are implementing an expanded compliance program for professional fee billing. The compliance plan has the following key features:

1. Designation of an official responsible for directing the effort to enhance compliance, including implementation of this plan;
   
   
2. Incorporation of standards and policies that guide _____ personnel with regard to professional fee billing;
   
   
3. Development of compliance initiatives at all applicable levels;
   
   
4. Coordination and enhancement of training of faculty physicians, residents, other healthcare providers and appropriate clinical/billing staff concerning applicable billing requirements and _____ policies;
   
   
5. A uniform mechanism for employees to raise questions and receive appropriate guidance concerning professional fee billing;
   
   
6. Regular chart and billing reviews by _____ employees to assess compliance and to identify potential issues; external consultants may be used as needed;
   
   
7. A process for employees to report instances of possible noncompliance and for such reports to be fully and objectively reviewed;
   
   
8. Regular reviews of the overall compliance effort, including Department/Unit/Section-specific plans, to ensure that billing practices reflect current requirements and that other adjustments are made to improve the program;
   
   
9. Formulation of corrective action plans to address any instances of noncompliance with _____ policies or billing requirements.

Chapter 2 -- Chief Compliance Officer

Responsibility for implementing and managing the Compliance Plan will be assigned to the Chief Compliance Officer (CCO). The CCO will function within the _____ organizational structure. A Compliance Plan Implementing Committee, consisting of departmental compliance leaders drawn from clinical departments and other areas across the clinical enterprise will be constituted to implement this Plan, the chair of which will be the CCO. The CCO will, with assistance of counsel when appropriate, perform the following activities:

1. Review, revise, and formulate appropriate policies to guide billing of professional fees;
   
   
2. Review, revise and approve Department/Unit/Section compliance plans, including policies relating to billing and documentation;
   
   
3. Assist with the development of training materials and programs, as needed;
   
   
4. Review and approve training materials and programs;
   
   
5. Oversee chart and billing reviews conducted by both internal and external auditors/consultants;
   
   
6. Develop/recommend systems and processes to optimize compliance;
   
   
7. Review any inquiries concerning billing or reports of non-compliance by determining whether a compliance issue exists and, if so, developing an appropriate response;
   
   
8. Develop appropriate corrective action plans to address any compliance issues;
   
   
9. Prepare an annual report that summarizes the compliance effort, both for the _____ and for individual Departments/Sections, and identify changes that will be made to enhance compliance.

The CCO will work closely with the departmental compliance leaders to foster and enhance compliance with all applicable billing requirements. The CCO shall have the authority to direct specific billing practices, including, but not limited to, 1) the use of particular codes for designated services, 2) the procedures and practices used to handle billing, and 3) the imposition of restrictions on billing by particular physicians, groups of physicians, or other health professionals. The CCO should consult with other _____ personnel, including, for example, the Chair of the affected department, in an effort to resolve issues through consensus. The authority of the CCO shall extend to all billing for clinical services -whether on a fee for service basis or otherwise provided by _____ employees.

Chapter 3 -- Policy Guidelines

It is the policy of _____ that all claims for professional fee reimbursement use the proper code for the service provided, that the documentation in the medical record supports the code, and that the claim is submitted in the name of the appropriate provider. To guide physicians, residents, other healthcare providers and appropriate clinical/billing staff in meeting this objective, the CCO shall, with the assistance of legal counsel if necessary, review existing policy statements, revise those statements as necessary, and develop any additional statements that seem advisable. _____ policies concerning billing should be considered an integral part of this Plan. These policies may be changed periodically.

Chapter 4 -- Departmental Implementation Plans

Each clinical department shall appoint a physician faculty member to serve as the compliance leader for departmental billing activities. The departmental compliance leader will coordinate departmental compliance activities with the CCO. The CCO shall have regular contact with the compliance leaders. Each clinical department shall prepare a plan to address compliance efforts on a departmental basis. The department plan shall be equal to or more stringent than the _____ plan requirements. Before becoming effective, such plans shall be reviewed and approved by the CCO to ensure consistency with _____ policies. If the CCO has concerns about the content of any departmental plan, he/she should consult with the Department Compliance Leader to explore whether the plan can be modified through mutual agreement. If such consultation fails to resolve the CCO's concerns, the CCO shall have the authority to modify the departmental implementation plan. The departmental implementation plans shall, at a minimum, include the following features:

1. Written policies and procedures for any billing activities;
   
   
2. Educational and training programs, as coordinated with the CCO and _____, to address billing issues of particular importance to the department;
   
   
3. A program for ensuring and documenting that all physicians, residents, other healthcare providers and appropriate clinical/billing staff receive training about proper billing;
   
   
4. A program for periodic review of departmental billing;
   
   
5. An annual review of the existing compliance plan in order to identify the need for changes and to identify specific compliance objectives during the succeeding year.

Chapter 5 -- Education and Training

The CCO shall be responsible for disseminating and explaining _____ policies concerning billing. To accomplish those objectives, the CCO shall work with representatives of the Deans of the Colleges or their designees, the Departments, and _____ to implement a systematic and ongoing training program to educate existing staff and new personnel about _____ billing policies. All training materials concerning billing issues shall be submitted to the CCO for review and approval before being used.

Training shall be mandatory for all physicians, residents, other health care providers who bill for their services, and billing personnel. A system shall be developed to document that such training has occurred. Moreover, the CCO can require that these individuals attend additional training sessions on particular issues. The training materials shall identify the specific people who should be contacted by physicians, residents, other healthcare providers or appropriate clinical/billing staff about billing questions.

No outside billing consultant may be retained by the _____, or any Department, without the review and concurrence of the CCO. If there is disagreement about the need or appropriateness of seeking such consultation or about the suitability of the proposed consultant the CCO shall decide whether the consultant should be retained.

Chapter 6 -- Monitoring

Under the supervision of the CCO, a sample of medical records and corresponding bills for each department and section shall be periodically reviewed on a prospective basis for compliance with the _____ billing policies and with legal requirements. Each department shall be reviewed at least annually, but the CCO may require more frequent reviews. Moreover, on an annual basis, the CCO, in consultation with the _____ Executive Committee, may engage an external billing reviewer to review a sample of records drawn from a cross-section of departments. If any of these reviews identify possible instances of non-compliance with _____ billing policies and with legal requirements, the CCO shall report the matter to _____ Executive Committee, the Dean of the college whose billings are at issue, and legal counsel for _____. In consultation with legal counsel, the CCO then shall review the particular matter to determine whether there has been any activity inconsistent with _____ billing policies and legal requirements.

Chapter 7 -- Reporting Compliance Issues

The training materials will direct _____ employees to report to the CCO any activity that employees believe may be inconsistent with _____ policies or legal requirements regarding billing. The training materials will explain how the CCO can be contacted. The training materials will also provide the employees with information about programs and practices of _____ that are designed to achieve compliance with legal requirements. Employees who report possible compliance issues will not be subjected to retaliation or harassment as a result of the report. Concerns about possible retaliation or harassment should be reported to the CCO.

Chapter 8 -- Investigating Compliance Issues

Whenever conduct that may be inconsistent with a billing policy or requirement is reported to or discovered by the CCO, an investigation will be undertaken with the assistance of legal counsel. After review and investigation, the CCO shall prepare a written report of findings for the _____ Executive Committee and the Dean of the appropriate college. _____ employees must cooperate fully with any investigations undertaken by the CCO.

Chapter 9 -- Corrective Action Plans

Whenever non-compliance is identified by the _____ compliance staff, corrective action will be taken. The Chief Compliance Officer will meet with the departmental chair and/or compliance leader to review the findings and develop a corrective action plan within the department. If applicable, overpayments will be returned. If and when the Chief Compliance Officer determines that departmental remedies have not corrected the problem or problems, further corrective action, as described below, will be taken, depending upon the severity of the offense. In all cases, faculty will be given the opportunity to appeal decisions either at the department or _____ level.

Technical corrections made 9/11/97

Chapter 10 -- Revisions to this Plan

This Compliance Plan is intended to be flexible and readily adaptable to changes in regulatory requirements and in the healthcare system as a whole. The Plan shall be regularly reviewed and modified, as necessary. To facilitate appropriate revisions to the Plan, the Chief Compliance Officer shall prepare a report, at least annually, that describes the general compliance efforts that have been undertaken during the preceding year and that identifies any changes that might be made to improve compliance. This report shall be circulated to the _____ Executive Committee, _____ CEO, the Deans of the Colleges which utilizes the _____ billing systems and to others with an interest in compliance for their comments about possible revisions to the Plan. This Compliance Plan shall be presented to the _____ Board of Directors and _____ CEO for approval. Revisions to this plan require approval from the _____ Executive Committee and _____ CEO.

Closing Statement

The compliance program described in this document is intended to establish a framework for effective billing and legal compliance by _____. It is not intended to set forth all of the substantive programs and policies of _____ that are designed to achieve compliance. _____ have already established various compliance policies and those policies as well as future policies will be a part of its overall legal compliance enforcement program.

Approved by _____ Executive Committee: 1/20/97

Approved by _____ Board of Directors: 4/29/97

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