Policy: ConferMED Compliance Program
Effective: November 15, 2019
The Compliance Program shall consist of the following elements:
- Business Ethics, Professional Ethics, and Conduct
- Receipt of Gifts
- Fraud and Abuse Laws
- Patient Billing
- Privacy Protection Patient Health Information
- Utilizing Information Technology
- HIPAA Privacy Regulations
- Access to PHI
- Identity Theft – Red Flag Rules
- Training and Education
- Communication – Whistle Blower
- Problem Solution and Corrective Action
- Auditing and Monitoring
- Mission: ConferMED, which includes its management services organization, is committed to following state and federal laws and contractual obligations and to protecting against fraud, waste and abuse.
- Business Ethics, Professional Ethics, and Conduct: The Compliance Program adopted by ConferMED is applicable to all members of its Board of Directors, Officers, employees, contractors, and vendors with which it conducts business. ConferMED is committed to compliance with all federal, state and municipal laws, contractual obligations and the regulations and guidelines relating to its overall operations, and the prevention of fraud and abuse in the delivery of its services. The Compliance Program extends beyond business ethics to include professional ethics and conduct. Indeed, it is impossible to list all of the potential compliance concerns, therefore employees, Directors, Officers, contractors and vendors are encouraged to raise any issue of concern. Examples may include but are not limited to issues of billing, payment, documentation or inappropriate behavior.
- Conflicts – As ConferMED employees we assume the commitment and obligation to ConferMED’s clients and patients to act in a manner that will merit public trust and confidence and to avoid any action which would bring discredit to ConferMED. Each employee of ConferMED has a duty to make full disclosure of any situation in which his or her private interests create a conflict or potential conflict with those of ConferMED. It is important to remember that an appearance of conflict may be just as damaging to ConferMED’s reputation as a real conflict. In order that there is a common understanding of the importance of these matters, each employee shall be requested to sign a compliance form as an indication of understanding and compliance. Activities prohibited to an employee shall not be done, or knowingly permitted to be done, indirectly through relatives, friends or otherwise.
- Receipt of Gifts – No employee will, as part of his or her business activity, accept any gift, money or other thing of value, other than advertising, promotional or goodwill gifts of nominal value (less than $50.00). Good judgment must be exercised as to the cost, frequency, and intent to influence. Gifts outside these guidelines should be returned and an appropriate explanation of ConferMED’s policy provided to the donor.
- Fraud and Abuse Laws –ConferMED expects its employees to refrain from conduct that may violate the fraud and abuse laws. These laws prohibit:
- direct, indirect or disguised payments in exchange for the referral of patients:
- ordering of designated health services for patients from entities with which the attending clinician or an immediate family member has a financial interest;
- the submission of false, fraudulent or misleading claims to any government entity or third party payer, including claims for services not rendered, or claims which do not otherwise comply with applicable program or contractual requirements;
- making false representations to any person or entity in order to gain or retain participation in a program or to obtain payment for and service, and
- improper billing procedures including double billing, bundling and unbundling and miscoding.
All substantiated or confirmed fraud, waste or abuse allegations shall be reported to the appropriate parties, including any health plans that require such reporting.
- Patient Billing –The billing practices of ConferMED must comply with applicable Federal and State laws and the contractual obligation contained in the various grants under which it operates. All such billing must be based upon accurate charges for services actually rendered.
The reporting requirements mandated by the Federal Medicare and Medicaid Programs, and the various financial grants from state and municipal sources, require that an accurate daily record of all patient encounters and treatments be maintained. ConferMED shall provide appropriate training to individuals responsible for daily admissions, including procedures to:
- Record patient data, telephone, address, updated patient information, insurance verification, verification of Medicaid, self-pay and private insurance.
- Accurate posting of daily patient encounter date, including scheduled appointments and no-shows
- Basic working knowledge of coding procedures using ICD and CPT coding guidelines. The CPT codes explain what and the ICD-10 codes explain why provider services were performed. The proper use of these codes maximizes revenues from insurers while minimizing audit liability.
To assist each clinical provider in the proper use of these procedures, to the extent that ConferMED applicable, ConferMED shall:
- Provide current CPT/ICD- Coding manuals and appropriate training in their use.
- Conduct chart audits and other monitoring procedures on a periodic basis to assure understanding and compliance with coding requirements.
- Provide training programs, on at least annual basis, which shall include changes or revisions to the CPT/ICD coding procedures.
- Privacy Protection Patient Health Information – HIPAA mandates the security standards to protect an individual’s health information while permitting appropriate access and use of that information by health care providers and health plans. These groups are allowed under the privacy standards to use, share health information for treatment, payment and operational functions. ConferMED has policies and procedures governing the use and disclosure of protected health information. See ConferMED’s HIPAA Privacy Policies and Procedures.
- Utilizing Information Technology
- Call recipient to confirm fax number
- Use a confidential cover sheet
- If receiving a fax – get it right away
- Do not leave sensitive or confidential information on answering machines
- Do not discuss any PHI unless you are sure of who is requesting it
- Cell phones can be intercepted, so be careful of what information is being provided
- Stay at the copier when copying PHI
- Retrieve the original
- Identity Theft – Red Flag Rules –ConferMED has adopted an Identity Theft Prevention Program to detect, prevent and mitigate identity theft in connection with the opening of a covered account or any existing covered account.
Identity theft is a fraud that is attempted or committed using the identifying information of another person without authorization. It is usually financial in nature, but may be medical identity theft. This would involve the appropriate misrepresentation of individually identifiable health information to obtain access to medical services.
The policy adopted by ConferMED outlines the circumstances which indicate the possibility of identity theft and the procedures to be followed when such theft is suspected or identified.
- Training and Education – Access to a copy of the Compliance Program shall be provided to members of the Board of Directors, Officers, all employees, and vendors with which ConferMED conducts business. Each new employee of ConferMED shall, as part of his/her orientation program, be informed about the compliance program and the procedures by which they may report areas of suspected non- compliance. Additional training shall be provided to all ConferMED staff relative to compliance issues on an annual basis. The focus of these sessions shall be to reinforce ConferMED’s commitment to compliance with all laws, regulations, grant obligation and guidelines and policies of private payers.
- Communication: Whistle Blower – All employees of ConferMED are encouraged to seek clarification regarding any aspect of the compliance program, or report any issue which he or she may consider to be a prohibited policy or activity directly to their supervisor or the Compliance Officer. If something seems wrong, trust your instincts, say something. A report can help prevent mistakes or correct situations before they become more serious.
ConferMED is committed to patient safety, quality and employee satisfaction. ConferMED is committed to a transparent organization in which concerns and feedback can be freely expressed. Recognizing that not all employees have had prior experience of working in a transparent, non-punitive culture, ConferMED maintains an anonymous and confidential “hotline” for administrative compliance concerns. Direct access to this confidential phone in the office of the Compliance Officer is extension 3535.
ConferMED will take no disciplinary or retaliatory action because an employee reports safety or quality concerns to either their immediate supervisor or Compliance Officer.
The Compliance Officer shall provide written acknowledgement of the inquiry and/or complaint, and conduct a prompt investigation of the subject matter. The Compliance Officer shall initiate an investigation into the matter as quickly as possible but in no event later than 2 weeks after receipt of an inquiry or complaint. Upon completion of the inquiry, the Compliance Officer shall provide a written report to the complainant, if known, of his findings and corrective actions, if any, which have been recommended or implemented. The Compliance Officer shall maintain a record of all inquiries and responses and submit a summary report to the Board of Directors at least once a year.
- Problem Solution and Corrective Action – Upon determination that a problem or unusual trend has been disclosed an internal investigation shall be undertaken to determine its cause, scope and seriousness. If the matter involves improper coding ConferMED shall determine whether overpayments have resulted, and if so, refunds shall be promptly provided to the applicable payer. Corrective measures shall be implemented to avoid repetition of such incorrect coding.
The Compliance Officer shall maintain a record of all alleged violations, a description of the investigative process, copies of all notes and reports, the results of the investigation, including any disciplinary action taken, and all corrective action implemented.
- Auditing and Monitoring – To ensure adherence to ConferMED’s policies and procedures, and to identify areas of potential risk which may require special attention, ConferMED shall conduct, at least annually, a review of the compliance program. Such review shall include participation of the education programs, coding accuracy, effectiveness of communication of policy and regulatory updates or changes, and responses to inquiries or complaints submitted to the Compliance Officer.
- Enforcement – The Compliance Policy of ConferMED shall be consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense, as well as those individuals who actually committed or conducted an offense. The form of discipline that will be appropriate will be case-specific.