Procedures-Compliance Program
Compliance officer responsibilities
-Report regularly to the ATCEMS executive team; -oversee the implementation and entire administration of policies; -develop programs to educate and train ATCEMS personnel with respect to compliance; -ensure that any potential violations or irregularities are properly investigated and addressed; -perform a review due diligence work as it applies to the billing practices of ATCEMS; -conduct research on trends and third-party reimbursement, including but not limited to Medicare and Medicaid; -be available to discuss, confidentially, employee concerns regarding compliance with the law and ATCEMS's policy and procedures; -oversee both internal and external reviews; -assist management in communicating with the Medicare carrier, and federal or state agencies to discuss reimbursement issues.
If a patient is unable to sign, who is able to sign in his or her place?
-The beneficiary's legal guardian; -A relative or other person who receives Social Security or other governmental benefits on behalf of the beneficiary; -A relative or other person who arranges for the beneficiary's treatment or exercises other responsibility for his affairs; -A representative of an agency or institution that did not furnish the services for which payment is claimed, but furnished other chair, services, or assistance to the beneficiary.
What subjects are involved in billing personnel's required training? How often will this training occur?
-claims processing -claim submission -billing -Coding -medical necessity -Reimbursement matters -training is annually.
Examples of activities that could violate federal false billing laws
-filing a claim for goods and services that were not provided or were not provided as described on the claim; -filing a claim for services without documentation to substantiate the performance of the services; -Submitting a claim containing information known to be false; -filing a claim for a higher level of service then was provided; -adding false diagnoses; -using past diagnosis to represent the patient's current medical condition; -routinely billing Medicare patients at rates higher than private patients; -Falsifying the origin or destination; -using incorrect modifiers; -billing excess mileage or for unloaded mileage; -submitting a claim to Medicare for reimbursement without a patient or qualified signature; -billing or accepting reimbursement for services which were not medically necessary.
What happens if billing personnel encounter uncertainties when submitting a claim for reimbursement?
-first, billing personnel shall bring the issue to the attention of their supervisor. If uncertainty still exists, the supervisor shall discuss the issue with a compliance officer. -If the uncertainty still continues, the payer should be contacted by telephone with written follow up, in an attempt to resolve the issue.
What items must be in a PCR in order for it to be considered complete?
-patient's condition at the time of dispatch (call nature); -patient location; -destination; -patient's name; -patient's date of birth; -patient's address; -chief complaint at time of transport; -vital signs; -treatment rendered; -narrative; -patient's past medical history; -patient's signature or alternate signature; -loaded transport miles; -Field provider signatures.
Who is responsible for annual billing training? Who else works with them to develop this training?How long is this training at a minimum?
ATCEMS billing management is responsible. They work with the compliance officer.The training will be at least two hours.
Who are the gatekeepers for compliance?
ATCEMS billing personnel
Pre-bill review
ATCEMS is responsible for implementing and maintaining a daily process for pre-bill review of Medicare and other federal/state program claims to ensure that all claims submitted for reimbursement accurately represent the medical condition of the patient, the services provided, and that all information submitted is supported by complete documentation, including patient signatures are required alternative documentation.
Who handles questions related to ATCEMS's HIPAA procedures?
ATCEMS privacy officer liaison
Coders
Coders are responsible for translating the documentation of the care of a patient and therefore must: Review all transport documentation in order to correctly apply the following codes: -Condition codes; -Medical necessity codes (questions and answers establishing the grounds for the medical necessity of transport); -denial codes for the Medicare and/or Medicaid claims not meeting coverage criteria; and -System codes (such as location, charges, and modifiers)
Condition codes
Coders must follow accepted standards for application of condition coding: -Use presenting (or current) condition as the primary condition code; -Use medical history only if it impacts the medical necessity of the patient's current transport (i.e. contractures of the lower extremity's or patient is comatose); and -Used condition codes as required by federal and state requirements.
Mandatory signed privacy document in all ATCEMS employees personnel file
Confidentiality and Dissemination of Patient Information and Staff Member Verification
Non-stretcher transport
If a patient is not transported by stretcher, we must ensure that ATCEMS is not reimbursed by Medicare. Medicare's definition of medical necessity is when the patient's condition, at the time of transport, is such that the use of any other method of transportation is contraindicated. Billing personnel are required to change the ambulance certification to "no "for transported by stretcher and then add the "GY "modifier for Medicare patients.
Who are expected to promote and explain the billing program to all billing personnel?
Managers and supervisors.
Medicaid Medical necessity
Medicaid deems an emergency transport as a benefit when the patient has an emergency medical condition manifesting itself by acute symptoms of sufficient severity including severe pain psychiatric disturbance or symptoms of substance-abuse such that a prudently person with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in one of the following: placing the patient's health (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment of bodily functions, serious dysfunction of any bodily organ or part.
Medicare Medical necessity
Medical necessity is established from the patient's condition, at the time of transport, is such that the use of any other method of transportation is contra indicated. If other modes of transportation could have been used without endangering patient health, then ATCEMS cannot submit claims for reimbursement by Medicare.
Origin/Destination modifiers
Medically necessary ambulance transport for Medicare beneficiaries is covered to/from approved destinations. When billing Medicare, the origin and destination of the transport are reported with single character modifiers. These modifiers must be reported accurately based on the Medicare carrier direction and state published facility lists. Inaccurately coded origin/destination modifiers may misrepresent the nature of the ambulance transport and result in inappropriate claims for Medicare reimbursement.
Level of service
Medicare and Medicaid recognizes multiple levels of ambulance services; basic life support (emergent and non-emergent; ATCEMS does not provide nonemergent services), ALS1 (emergent and non-emergent, ATCEMS does not provide non-emergent services), ALS2 in specialized care transport (currently ATCEMS does not provide the service). It is the responsibility of billing personnel to review intake/dispatch information and PCR documentation to determine the accurate level of service for billing purposes.
Patient signatures
Medicare and other insurance carriers requires a signature of the beneficiary or that of his representative for both the purpose of accepting assignment and submit your claim to Medicare. If the patient is unable to sign because of a mental or physical condition, the following individuals may sign the claim form on behalf of the beneficiary: -The beneficiary's legal guardian; -A relative or other person who receives Social Security or other governmental benefits on behalf of the beneficiary; -A relative or other person who arranges for the beneficiary's treatment or exercises other the responsibility for his affairs; -The representative of an agency or institution that did not furnish the services for which payment is claimed, but furnished other care, services, or assistance to the beneficiary. Failure to have an appropriate signature on file for Medicare beneficiaries will result in the account being placed in the "signature required" schedule, with invoices requesting the signature be processed every 30 days and will not be submitted until the signature or qualified signature is received.
How does Medicare reimburse if two patients or transported in the same ambulance to the same destination?
Medicare will pay up to 75% of the single patient allowed amount applicable to the level of service furnish the beneficiary for each patient +50% of the total mileage payment allowance for the entire trip. This percentage applies to each beneficiary transported regardless of whether or not everybody is an eligible beneficiary or not.
What are three examples of federal healthcare programs?
Medicare, Medicaid, CHAMPUS.
Mileage
Mileage must be documented on the PCR for every transport based on loaded miles. Medicare requires that ambulance providers report mileages to the nearest 10th of a mile. For PCRs that have incomplete mileage, a supervisor must be notified to verify and correct the mileage by using approved mapping software.
How does Medicare reimburse if three or more patients are transported to the same destination simultaneously?
The allowance for the Medicare beneficiary or for each patient is 60% of the base rate applicable to the level of care provided to the beneficiary. However, a single payment allowance for mileage will be prorated by the number of patients on board.
Verification review
The billing department will verify each account after pre-bill review and prior to submission for accuracy and charges, services, modifiers, and mileage.
Compliance standards for billing personnel
The billing operation is responsible for maintaining current written procedures that provide step-by-step direction for all employees involved in the billing process. These written procedures must incorporate standards and provide adequate checks and balances to ensure full compliance and all functions as defined below
Who serves as the compliance officer? Who assists the compliance officer?
The customer care program manager. The compliance officers assisted by the executive team, managers, and administrative personnel.
Billing personnel's primary responsibility
They are responsible for review and interpretation of all documentation prior to claim submission for reimbursement or denial. The duties and responsibilities identified within this program or the minimum acceptable standards in order to be used as a guide in the development of billing policies and procedures.
