COMPLIANCE
AND
REGULATORY
INSURANCE/ PAYERS
• Regulatory system: CMS( centre for medicare and Medicaid service)
• Two types:
Government Private or commercial
-less expensive -more expensive
-has limitation -customizable (individual plans or
-Examples are : group plans)
Medicare , Medicaid, -Examples are: Aetna, Cigna, etc..
CHAMPVA, COBRA, etc..
Medicare Program
• started in 1965
• maintained by CMS
• For people over 65 and younger people with disabilities or ESRD
• Claims are processed by Medicare administrative contractor (MAC)
Part A Part B Part C Part D
medically necessary preventive care Advantageous plan Covers prescription
services
in patient services out patient services Combination of Part for all medicare
A, B and D beneficiaries
processed through processed through processed by processed by
a form called UB04 a form called private insurance private insurance
cms1500 approved by approved by
medicare medicare
Medicaid Program
• Federal health care program for low income people(children and pregnant
women)
• Administered by state government with federal guidelines
• Coverage and benefits vary by states
• Federal government sets minimum coverage reuirements
• Examples of state funded programs for children upto 21:
• crippled children service
• childrens medical services
• some minimum covered services are IP/OP services, Family planning services,etc.
Other government insurance
types
• CHAMPVA- Civilian health and medicare program of the department of
veterans affairs
• COBRA(consolidated omnibus Recollection Act)
• CHIP(Children health insurance program)
• TRICARE- Previously called as CHAMPUS(civilian health and medical
program of uniformed services)
• Workers compensation Insurance
• BLUE CROSS BLUE SHEILD(BCBS)
Medical Necessity
• least radical service that allows effective treatment to the patient
complaints
• Medicare pays service that meets medicare standard of reasonable and
necessary diagnosis under NCD & LCD
• MAC is responsible for interpreting national policies into local or regional
• Non-medicare payers may develop their own policies that are different
from medicare
ADVANCE BENEFICIARY NOTICE(
ABN)
• standardized form to explain why medicare may deny a particular
service
• should be signed before providing the service
• It allows you to decide whether to get care and to accept financial
responsibility for the service if medicare denies payment
• Non-medicare(private) payers may not recognize ABN
HIPAA
• Health Insurance Portability and Accountability Act
• Federal law of 1996
• ensures privacy, confidentiality ,security and encourage electronic data
interchange
• It covers providers, Health Plan, Healthcare clearing house
• key provision is “ minimum Necessary”of PHI- protected health information
• following details can be allowed:
-Disclosure of details for treatment purpose
-Disclosure to the US department of health and human services(HHS)
-Disclosure of information to the patient himself
-Disclosure made pursuant to an individual’s authorization.
-Disclosures required by law
HITECH
• Health information technology for economic and clinical Health Act
• given as a part of American Recovery and Reinvestment Act of 2009(ARRA)
• strengthens HIPAA and also electronic transmission of health information(EDI)
• allows patient to request for audit trail of patient health information through
electronic record
• notifies patient if there is unauthorized disclosure of information
Fraud
• bill for services that has a higher reimbursement than the service provided
• unbundling: coding the procedure that is already covered by another code
• Overcoding: billing for costly procedure than the one performed
• Cloning: falsifying the diagnosis to justify the test, surgery and other procedures
• Billing for procedures that is not actually performed
• Misrepresenting procedure performed to obtain payment for non covered
services such as cosmetic services
Abuse
• practices that may directly or indirectly result in unnecessary cost to the
medicare program
• Examples are:
• billing for unnecesaary service
• Charging excessively for services
• Misusing the codes
COMPLIANCE
• written set of instructions outlining the process for coding and
submitting accurate claims and what to do if mistakes are found
• Benefits:
-More accurate payment of claims
-Fewer billing mistakes
-Improved documentation
-Less chance of violating self referral and anti kickback statues
OIG work plan
• OIG( office of inspector general)
• Every year October OIG releases a work plan
• Key actions of compliance program include:
a)Implement compliance and practice standard
b)Designate compliance officer
c)Conduct training and education on practice standards
d)Conduct internal monitoring and auditinglike meetings to avoid errors or
fraud, bulletin board etc.
e)Respond appropriately to detected violation
f)Develop open communications
g)Enforce disciplinary standards through well publicized guidelines
RBRVS( Resource based relative
value service)
• determine how much money providers should be paid
• The resource cost are divided into 3 components: Physician
work(52%), Practice expense(44%), Professional liability
insurance(4%)
• Based on the 3 factors aRVU(relative value unit ) will be fixed
RBRVS =RVUxCF
COMPLIANCE TERMINOLOGIES
• Medical Necessary
• RVU: specific value multiplied by a dollar conversion factor
• Miscoding: Incorrect coding
• Unbundling
• Upcoding
• Provider
• Payer
• Non facility
• facility
• HMO: Health Maintenance Organization
• In Network providers/Par providers(participating provider):
Providers have contracted with insurance company to accept certain
DISCOUNTED rates of services, so the fee is less.
• Out of network Providers/Non par providers(non participating)
• Assignment of Benefits(AOB)
• Co-ordination of Benefits(COB)
• Explanation of benefits(EOB): also called as Remittance advice R/A.
• Fiscal intermediary(FI)
• PPO(Preferred provider organization)
• Deductible
• Coinsurance
• Copay
Global Surgical Indicators
• medicarePhyscian Fee schedule(MPFS) gives the surgical indicators to show the
global period or post operative period
• Codes 000- no post operativeperiod
• Codes 010- minor procedures with 10 days of post op
• Codes 090- major surgeries wITHindicate 90 days of post op
• Codes YYY shows contractor priced codes
• Codes ZZZ- add on codes
• Codes XXX- global concept does not apply (radiology/ pathology)
Category 2 codes
• Supplemental codes/ optional codes
• Used for performance measurement
• Ends with letter F
• Doesn’t not substitute category 1 codes
• Doesn’t have any billing value
• adopted and reviewed by performance Measures Advisory Group(PMAG)
• Category 2 ease the review of HEDISTMI performance and also used to
participate in medicare’s PQRS program
Category 3 codes
• Temporary codes
• Used for emerging new technology
• Ends with letter T
• Substitute category 1 unlisted codes
• Payer fixed billing value
