Chapter 3 CPCO - Other Applicable OIG
Compliance Program Guidance
Churning
"Churning" means the fluctuating between Medicaid
and unsubsidized private insurance of patients with
unstable incomes. It has the potential to greatly
impact continuity of care in the health insurance
marketplace (HIM).
"Pass-Through"
Pass-through items are certain items of new
technology and drugs for which Medicare will
reimburse hospitals based on costs during a
limited transitional period.
Unbundling codes
When a billing entity uses separate billing codes for services that have an aggregate
billing code.
Up-Coding
Diagnosis-related group (DRG) creep
Jenneheheh
Inappropriate balance billing
Inadequate resolution of overpayments
Lack of integrity in computer systems
What should be readily accessible to all coding staff?
• Billing certification
• CPT™ codebook
• All essential coding resources
• Nursing handbook
All essential coding resources
Coders must have up-to-date resources to code correctly and send out correct
claims.
What can providers review that will help them understand the compliance
requirements of a clinical lab?
• Laboratory Provider Handbook
• OIG's Clinical Lab Guidance
• OIG Developing an Effective Compliance Program
• Physician Desk Reference
OIG's Clinical Lab Guidance
,The OIG Clinical Lab Guidance provides pertinent information on effective
compliance and risk areas for laboratories.
Skilled Nursing Facilities (SNFs) are Medicare-certified facilities that provide
extended skilled nursing or rehabilitative care. This care is reimbursed under which
Medicare part(s)?
A
B
C
Part A and Part B
Part A and Part B
They SNFs are typically reimbursed under Part A for the costs of most items and
services, including room, board, and ancillary items and services. However, SNFs
may also receive payment under Medicare Part B.
How many states currently require nursing facilities to perform a background check
of state records for direct-access employees?
10
35
43
50
43
Out of 50 states, 43 have mandated background check requirements for individuals
who have direct contact with SNF patient and/or their personal possessions.
How many states require nursing facilities to perform a FBI checks on employees?
3
5
10
27
10
Out of 50 states, 10 states have mandated nursing homes perform an FBI
background checks on employees.
Which of the following should be reflected in a billing company's written policies and
procedures?
• Current Federal statutes only
• Current Federal and state statutes
• Current regional and Federal statutes
• Current state statutes only
Current Federal and state statutes
With respect to claims, a billing company's written policies and procedures should
reflect and reinforce current federal and state statutes.
What third party plays a critical role in accurate billing and reimbursement?
,• Billing agencies
• Laboratories
• Nursing facilities
• Office of Inspector General (OIG)
Billing agencies
Providers have come to rely on billing agencies over the years to send out correct
claims on their behalf.
What should not be ignored and may require necessary policy measures to prevent
avoidable recurrence?
• Compliance program
• Control measures
• Risk areas
• Work flow
Risk areas
Monitoring risk areas will indicate vulnerable areas for fraud and abuse that need
addressing. Compliance officers can use the results to develop any necessary
policies and procedures.
What law(s) does not require that nursing facilities conduct state or Federal FBI
Bureau of Investigation criminal background checks?
• False Claims law
• Federal law
• Federal and state laws
• State law
Federal law
Federal law does not require that nursing facilities conduct state or Federal Bureau
of Investigation FBI criminal background checks. State laws may, however. It is
important to confirm both sources for applicable laws.
Why should compliance officers have set disciplinary policies for non-compliance?
• Employees need rules to follow.
• Employees should know the consequences for non-compliance of set policies.
• Employees should know what is expected of them.
• Employees need to understand policies set in place.
Employees should know the consequences for non-compliance of set policies.
There should be clear communication of what is expected of employees and equally
clear communication of the consequences for not following written policies.
Tim is the Compliance Officer for a billing company. The CEO wants to know, in
addition to policies & procedures, what other item is important for third parties to
integrate into their compliance program. What should Tim's response be?
, • The compliance plan should be written to a national level and include federal health
insurance program guidelines only.
T• he compliance plan should be written to state level and include state health
insurance program guidelines only.
• The compliance plan should be written to a local level and include local regulations
only.
• The compliance plan should include regulations that affect the billing company,
including federal and state statutes, regulations, and health insurance guidelines.
The compliance plan should include regulations that affect the billing
company, including federal and state statutes, regulations, and health
insurance guidelines.
Besides policies & procedures, third parties should integrate federal and state
statutes, regulations, and health insurance guidelines into their compliance program.
Which factor is NOT considered in the OIG Work Plan?
• Mandatory requirements for OIG reviews, as set forth in laws, regulations, or other
directives.
• Requests made or concerns raised by Congress, HHS management, or the Office
of Management and Budget.
• Top management and performance challenges facing HHS.
• Inconvenience to the healthcare industry.
Inconvenience to the healthcare industry.
The OIG Work Plan considers a number of factors including: Mandatory
requirements for OIG reviews, as set forth in laws, regulations, or other directives;
requests made or concerns raised by Congress, HHS management, or the Office of
Management and Budget; top management and performance challenges facing
HHS; work performed by partner organizations; management's actions to implement
our recommendations from previous reviews; and timeliness.
As the new Compliance Officer for XYZ Billing Company, when should Tim start a
compliance program for the third-party healthcare company?
Within the next few years because it is not a requirement
Now, to be proactive
Within the next few years because it's always best to be reactive with compliance
Tim should wait and determine how many fraud violations occur within the next year
before creating a compliance program.
Now, to be proactive
The time is right now for third-party healthcare companies to implement strong,
compliance programs.
Kim is the Compliance Officer at ABC Hospital. A provider asks her if Medicare pays
for all tests ordered by providers. Based on the OIG compliance guidance, how
should Kim respond?
• Yes, Medicare will pay for tests as long as the physician believes it is appropriate.
Compliance Program Guidance
Churning
"Churning" means the fluctuating between Medicaid
and unsubsidized private insurance of patients with
unstable incomes. It has the potential to greatly
impact continuity of care in the health insurance
marketplace (HIM).
"Pass-Through"
Pass-through items are certain items of new
technology and drugs for which Medicare will
reimburse hospitals based on costs during a
limited transitional period.
Unbundling codes
When a billing entity uses separate billing codes for services that have an aggregate
billing code.
Up-Coding
Diagnosis-related group (DRG) creep
Jenneheheh
Inappropriate balance billing
Inadequate resolution of overpayments
Lack of integrity in computer systems
What should be readily accessible to all coding staff?
• Billing certification
• CPT™ codebook
• All essential coding resources
• Nursing handbook
All essential coding resources
Coders must have up-to-date resources to code correctly and send out correct
claims.
What can providers review that will help them understand the compliance
requirements of a clinical lab?
• Laboratory Provider Handbook
• OIG's Clinical Lab Guidance
• OIG Developing an Effective Compliance Program
• Physician Desk Reference
OIG's Clinical Lab Guidance
,The OIG Clinical Lab Guidance provides pertinent information on effective
compliance and risk areas for laboratories.
Skilled Nursing Facilities (SNFs) are Medicare-certified facilities that provide
extended skilled nursing or rehabilitative care. This care is reimbursed under which
Medicare part(s)?
A
B
C
Part A and Part B
Part A and Part B
They SNFs are typically reimbursed under Part A for the costs of most items and
services, including room, board, and ancillary items and services. However, SNFs
may also receive payment under Medicare Part B.
How many states currently require nursing facilities to perform a background check
of state records for direct-access employees?
10
35
43
50
43
Out of 50 states, 43 have mandated background check requirements for individuals
who have direct contact with SNF patient and/or their personal possessions.
How many states require nursing facilities to perform a FBI checks on employees?
3
5
10
27
10
Out of 50 states, 10 states have mandated nursing homes perform an FBI
background checks on employees.
Which of the following should be reflected in a billing company's written policies and
procedures?
• Current Federal statutes only
• Current Federal and state statutes
• Current regional and Federal statutes
• Current state statutes only
Current Federal and state statutes
With respect to claims, a billing company's written policies and procedures should
reflect and reinforce current federal and state statutes.
What third party plays a critical role in accurate billing and reimbursement?
,• Billing agencies
• Laboratories
• Nursing facilities
• Office of Inspector General (OIG)
Billing agencies
Providers have come to rely on billing agencies over the years to send out correct
claims on their behalf.
What should not be ignored and may require necessary policy measures to prevent
avoidable recurrence?
• Compliance program
• Control measures
• Risk areas
• Work flow
Risk areas
Monitoring risk areas will indicate vulnerable areas for fraud and abuse that need
addressing. Compliance officers can use the results to develop any necessary
policies and procedures.
What law(s) does not require that nursing facilities conduct state or Federal FBI
Bureau of Investigation criminal background checks?
• False Claims law
• Federal law
• Federal and state laws
• State law
Federal law
Federal law does not require that nursing facilities conduct state or Federal Bureau
of Investigation FBI criminal background checks. State laws may, however. It is
important to confirm both sources for applicable laws.
Why should compliance officers have set disciplinary policies for non-compliance?
• Employees need rules to follow.
• Employees should know the consequences for non-compliance of set policies.
• Employees should know what is expected of them.
• Employees need to understand policies set in place.
Employees should know the consequences for non-compliance of set policies.
There should be clear communication of what is expected of employees and equally
clear communication of the consequences for not following written policies.
Tim is the Compliance Officer for a billing company. The CEO wants to know, in
addition to policies & procedures, what other item is important for third parties to
integrate into their compliance program. What should Tim's response be?
, • The compliance plan should be written to a national level and include federal health
insurance program guidelines only.
T• he compliance plan should be written to state level and include state health
insurance program guidelines only.
• The compliance plan should be written to a local level and include local regulations
only.
• The compliance plan should include regulations that affect the billing company,
including federal and state statutes, regulations, and health insurance guidelines.
The compliance plan should include regulations that affect the billing
company, including federal and state statutes, regulations, and health
insurance guidelines.
Besides policies & procedures, third parties should integrate federal and state
statutes, regulations, and health insurance guidelines into their compliance program.
Which factor is NOT considered in the OIG Work Plan?
• Mandatory requirements for OIG reviews, as set forth in laws, regulations, or other
directives.
• Requests made or concerns raised by Congress, HHS management, or the Office
of Management and Budget.
• Top management and performance challenges facing HHS.
• Inconvenience to the healthcare industry.
Inconvenience to the healthcare industry.
The OIG Work Plan considers a number of factors including: Mandatory
requirements for OIG reviews, as set forth in laws, regulations, or other directives;
requests made or concerns raised by Congress, HHS management, or the Office of
Management and Budget; top management and performance challenges facing
HHS; work performed by partner organizations; management's actions to implement
our recommendations from previous reviews; and timeliness.
As the new Compliance Officer for XYZ Billing Company, when should Tim start a
compliance program for the third-party healthcare company?
Within the next few years because it is not a requirement
Now, to be proactive
Within the next few years because it's always best to be reactive with compliance
Tim should wait and determine how many fraud violations occur within the next year
before creating a compliance program.
Now, to be proactive
The time is right now for third-party healthcare companies to implement strong,
compliance programs.
Kim is the Compliance Officer at ABC Hospital. A provider asks her if Medicare pays
for all tests ordered by providers. Based on the OIG compliance guidance, how
should Kim respond?
• Yes, Medicare will pay for tests as long as the physician believes it is appropriate.
