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Medicare Compliance Program Backgrounder

Communications with billing departments and compliance officers

Communications with Billing Departments and Compliance Officers
As RDs participate in the Medicare Part B program, it will be important to communicate with billing department staff and compliance officers so all parties recognize and apply compliance guidelines that impact Medicare MNT. This responsibility can elevate RDs' practice and participation in billing procedures to new levels within the hospital, physician clinic and private practice setting. Not only should RDs bill according to Medicare compliance guidelines, but practitioners should also contribute to their facilities' compliance program to safeguard against fraud and abuse.

To increase RDs' understanding of compliance program guidelines and compliance officers' responsibilities, as developed by the Office of the Inspector General (OIG) of the Department of Health and Human Services agency, the following information is presented. This can assist RDs with their communication and interaction with compliance officers and/or billing department staff.

ADA Member Tips for Communicating with Compliance Officers Officer/Billing
Department Personnel:
RDs may need to provide their billing department staff with copies of the Centers for Medicare & Medicaid Services (CMS) Medicare MNT Benefit Program Memorandums,” Medicare enrollment forms, and other information from your local Medicare carrier. As needed, convening a three-way dialog between the local Medicare carrier, the billing department staff and the RD provider will support understanding enrollment and claims procedures for the Medicare MNT benefit.

The following tips can help RDs prepare for discussions with compliance officers or billing department staff.

Compile data and billing related materials for discussions with your facilities' compliance officer and/or billing department staff.
Anticipate questions the compliance officer may ask about your billing practices, eg, what types of services were rendered, over what time frame. Be prepared to discuss your services and billing systems.
Always document discussions, conclusions or next steps for any communication you have with your billing team and/or compliance officer.

Why have a Compliance Program?
The OIG believes an effective compliance program provides a mechanism that brings the public and private sectors together to establish safeguards against fraud and abuse, improve the quality of healthcare, and reduce costs of healthcare. The program is one means to fulfill an organization/clinic's legal duty to ensure that it is not submitting false or inaccurate claims to government and private payers.(1)

OIG has issued final guidance to help individual and small group physician practices design voluntary compliance programs. OIG has also released proposed updated hospital compliance guidelines in the Federal Register.(2) To describe components of a compliance program, OIG has identified seven key components. One key point is the identification of a compliance officer to coordinate the clinic's compliance program.(3)

Compliance Officers' Responsibilities(1):
OIG recommends every billing company, hospital, physician office, etc. should designate a compliance officer to serve as the focal point for compliance activities. This responsibility may be the individual's sole duty or added to other management responsibilities, depending upon the size and resources of the company/clinic and the complexity of the task. For those companies/clinics that have limited resources, the clinic could participate in the compliance programs of other providers, such as hospitals or other settings in which the physician practices.

The compliance officer's primary responsibilities should include:

Overseeing and monitoring the implementation of the compliance program;
Reporting on a regular basis to the company/clinic's governing body, CEO and compliance committee (if applicable) on the progress of implementation and assisting these components in establishing methods to improve the billing company's efficiency and quality of services and to reduce the billing company's vulnerability to fraud, abuse and waste;
Periodically revising the program in light of changes in the organization's needs and in the law and policies and procedures of government and private payer health plans;
Reviewing employees' certifications that they have received, reading and understanding the standards of conduct;
Developing, coordinating and participating in a multifaceted educational and training program that focuses on the elements of the compliance program and seeks to ensure that all appropriate employees and management are knowledgeable of, and comply with, pertinent federal and state standards;
Coordinating personnel issues with the billing company's human resources/personnel office (or its equivalent) to ensure that providers and employees do not appear in the “Cumulative Sanction Report;”
Assisting the billing company's financial management in coordinating internal compliance review and monitoring activities, including annual or periodic reviews of departments;
Independently investigating and acting on matters related to compliance, including the flexibility to design and coordinate internal investigations (eg, responding to reports of problems or suspected violations) and any resulting corrective action with all billing departments, providers and sub-providers, agents and, if appropriate, independent contractors;
Developing policies and programs that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation; and
Continuing the momentum of the compliance program and the accomplishment of its objectives long after the initial years of implementation.

The compliance officer must have the authority to review all documents and other information that are relevant to compliance activities, including, but not limited to, patient records (where appropriate), billing records and records concerning the marketing efforts of the facility and the billing company's arrangements with other parties, including employees, professionals on staff, relevant independent contractors, suppliers, agents, supplemental staffing entities and physicians. This policy enables the compliance officer to review contracts and obligations (seeking the advice of legal counsel, where appropriate) that may contain referral and payment provisions that could violate statutory or regulatory requirements.

Reporting errors
To review and resolve claims processing problems, communication among Medicare providers and their respective billing agencies and/or compliance officers is critical. Dietetics professionals should contact these individuals and as needed, as a group, confer with legal counsel.

Additional compliance resources are included on ADA’s Web page, the "Compliance and HIPAA" section at: http://www.eatright.org/advocacy/mnt.

http://oig.hhs.gov/authorities/docs/physician.pdf and http://oig.hhs.gov/authorities/docs/04/060804hospitaldraftsuppCPGFR.pdf
OIG Draft Supplemental Compliance Program Guidance for Hospitals, Federal Register Vol. 69, No. 110, June 8, 2004.
Family Practice Management — January 2001, “Seven Steps to Medicare Compliance — The OIG's voluntary compliance guidance can help your solo or small group practice prevent fraud and abuse,” Mark S. Kennedy, JD. http://www.aafp.org/fpm/20010100/41seve.html.

*The information is for reference use only and does not constitute the rendering of legal, financial, or other professional advice of the American Dietetic Association. (10/06)