Month: February 2020

Comparative Billing Reports

As part of the Centers for Medicare and Medicaid’s (CMS) continued focus on billing compliance, CMS has begun issuing Comparative Billing Reports (CBRs) to providers whose billing patterns are statistical outliers in comparison to their peers.

Although some Medicare Administrative Contractors (MACs) had been generating their own CBRs, CMS recently initiated a nationwide data mining initiative focusing on Medicare Part B billing data. The initiative compares billing data from an individual provider to state and national peer groups with formal reports being issued to providers who are deemed to be outliers in comparison to their peers.

CBRs are meant to be educational and assist providers in evaluating their compliance with Medicare’s coding and billing guidelines. Receiving a CBR doesn’t necessarily indicate that there is a problem. However, CMS does expect that providers who receive a CBR will perform a self-review of their coding and billing practices in order to determine why they are an outlier and correct any issues of non-compliance identified during the self-review.

In 2020, CMS has reviewed billing data and issued CBRs on shoulder arthroscopy. In 2019, some of the reviews and CBRs issued by CMS focused on;

  • Mohs microsurgery
  • Modifier 25 in Dermatology
  • Emergency Department services
  • Office visits, new and established
  • Subsequent hospital care

For more information on CMS’s CBR initiative, please visit their website.

If you receive a CBR and would like assistance reviewing your billing data for compliance with Medicare guidelines, please contact the Office of Healthcare Compliance at compliance.officer@uchc.edu or 860-679-4746.

2019 Annual Healthcare Compliance Training

As a recipient of financial reimbursement from the federal and state government for medical services provided to Medicare and Medicare patients, UConn Health is subject to the many laws that govern the Medicare and Medicaid programs. To help our employees navigate through these rules, the Office of Healthcare Compliance launched a healthcare specific training on December 20, 2019. This training is in addition to the University Compliance training, which focuses on institution-wide compliance topics, like the Code of Conduct and the State Code of Ethics. The Healthcare Compliance training includes an overview of the prevention of fraud, waste and abuse, financial conflicts of interest in healthcare and other top healthcare compliance topics.

Because Uconn Health is a diverse environment not every topic in the training will apply to all. However, all employees should be aware of certain healthcare compliance topics to be sure that the institution supports a culture of compliance.

If you have not yet competed the training, log into the Saba Online Learning Center and access “My Learning”. The Healthcare Compliance trainings are titled:

  • 2019 Annual Healthcare Compliance Training
  • 2019 Compliance Risks and Strategies

The training’s deadline for completion is March 19, 2020. Failure to complete the training by the deadline could result in disciplinary action, up to and including dismissal.

The Privacy Office and the Office of IT Security annual trainings share the deadline of March 19 for training completion. Please be sure to also complete:

  • 2019 Security Awareness Training
  • 2019 HIPAA Privacy Training

Elements of an Effective Compliance Program

Academic medical centers operate in a complex and highly regulated environment governed by a plethora of federal and state laws and regulations. As such, the establishment of an effective compliance and ethics program is necessary to adequately and responsibly safeguard institutions and carry out their various ethical, legal and fiduciary responsibilities. As a condition of participation, many federal programs, such as Medicare and Medicaid, mandate comprehensive compliance and ethics programs.

In addition to meeting its legal requirements of having an effective compliance and ethics program, the Office of Healthcare Compliance and the Office of University Compliance work together to prevent and detect compliance violations, mitigate damaging and costly risks, and promote a culture of compliance and ethics across all the University’s campuses.

Summarized herein, are some of the foundational elements of an effective compliance program, which are based on Chapter 8 of the Federal Sentencing Guidelines for Organizations.

1. Standards, Policies, and Procedures – Establish standards and procedures to prevent and detect criminal conduct and facilitate compliance.

2. Oversight and Accountability – Ensure high level personnel exercise reasonable oversight with respect to the implementation and effectiveness of the compliance and ethics program, and are knowledgeable about the content and operation of the program. Specific individual(s) within high-level personnel (e.g., Chief Compliance Officer) shall be assigned overall responsibility for the compliance and ethics program.

3. Performance of Due Diligence – Use reasonable efforts not to include any individual who the organization knew or should have known (through due diligence) to be engaged in illegal activities or conduct inconsistent with an effective compliance and ethics program.

4. Education and Communication – Establish effective training and education programs and take reasonable steps to communicate standards, procedures, roles and responsibilities, as well as other aspects of the program to members of the institution, including the governing authority, high level personnel, substantial authority personnel, organization employees, and the organization’s agents (as appropriate).

5. Internal Monitoring and Auditing – Take reasonable steps to ensure the compliance and ethics program is followed by monitoring and auditing to detect criminal activity, non-compliance, and program effectiveness, as well as establish and publicize a mechanism that allows for anonymous and confidential reporting without fear of retaliation.

6. Incentives and Enforcement – Consistently promote and enforce standards through appropriate incentives, as well as disciplinary measures for engaging in criminal conduct and/or failing to take reasonable steps to prevent or detect criminal conduct.

7. Response to Incidents – Take reasonable steps to appropriately respond to criminal conduct/non-compliance, and to prevent further similar conduct from occurring in the future, including any modifications to the organizations compliance and ethics program.