UBO Compliance Program RequirementsDHA UBO Contract Support Team

26 August 2014 at 0800-0900 EST28 August 2014 at 1400-1500 EST

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Agenda/Objectives

• Understand what compliance is and why it is needed• Understand compliance program requirements and best practices– roles and responsibilities for UBO program– quarterly audits

• Understand recent changes to the DOD UBO Compliance Audit Checklist and how to effectively use it

• Understand billing risk areas• Find ways to improve your compliance program• Compliance resources

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What is Compliance?

• To monitor the organization to ensure consistent application of laws and rules relating to the MTF billing process

• To ensure ethical billing and collections by identifying problem areas and to establish and implement solutions. The programmatic elements will include, but will not be limited to: – Medical records documentation– Data quality/coding– Billing– Accounting and fiscal law– Healthcare fraud, waste, and abuse

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Why Compliance?

• Advantages– Sets processes– Promotes efficiency– Supports the overall mission of providing quality health care – Protects against mistakes– Helps detect mistakes– Helps detect fraud (not anti-fraud)

• Helps you develop internal controls– Promote adherence to federal law

• IS REQUIRED (next slide)

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Definitions

• Must– requirements created by statute or regulation; no discretion

• Should– expectations identified in guidelines; discretion as to how you

accomplish effectiveness• Best Practices– procedures that work well for some facilities; may not work for

all

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Authorities

• Federal Managers Financial Integrity Act of 1982 (FMFIA)– Requires DoD to implement & assess the effectiveness of

financial management internal control– OMB Circular A-123, Management’s Responsibility for Internal

Control, and Appendix A, Internal Controls Over Financial Reporting (ICOFR)• Revenues and expenditures are properly recorded and accounted for on

financial and statistical reports

• Chief Financial Officer’s Act of 1990 (CFO Act)– Goal: Achieve reliable financial data & safeguard resources

from Fraud, Waste & Abuse (FW&A)

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Authorities

• OASD(HA)/TMA Memo, “Compliance Plan Implementation Policy” to ensure that MTFs establish and comply with compliance guidelines (Feb 28, 2002) – Establish a compliance plan focused on coding and billing

ethical conduct– Perform a compliance audit, using an effective audit tool, at

least quarterly

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Authorities

• ASD(HA) Memo, “Revision of Compliance Audit Requirements in the DOD 6010.15-M, “MTF UBO Manual, Nov 9, 2006”” (Feb 27, 2008) – Implements Third Party Collection quarterly audit requirements

per DOD IG Report NO. D-2007-108 “Outpatient Third Party Collection Program” (July 18, 2007)• Bills are generated and sent for patient encounters when

other health insurance information exists in CHCS.• Collections from insurance providers are adequately

followed up.• All errors and deficiencies found during audits are corrected.

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Authorities

• DoD 6010.15-M– Military Treatment Facility Uniform Business Office (UBO) Manual– Applies to anyone billing under Title 10 of the United States Code

• 10 USC 1095: Health care services incurred on behalf of covered beneficiaries: collection from third-party payers

• 10 USC 1079b: Procedures for charging fees for care provided to civilians• 10 USC 1085: Medical and dental care from another executive

department: reimbursement

– Chapter 2 – Compliance (currently under revision)• This guidance document shall be used as a tool to develop effective

internal controls that promote adherence to applicable Federal laws relating to healthcare billing requirements

• Applies to the MSA, TPC, and MAC programs as well as any other healthcare billing activities designated by the Department of Defense, such as resource sharing agreements

• Applies to all UBOs (i.e., government and civilian contractor staffed)

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Authorities

• The compliance audit must verify:1. Internal controls identified in this Manual and on the UBO

Compliance Audit Checklist have been implemented.2. Requirements for storage and deposit of funds are met.3.* MTFs have billed insurance providers for patient encounters

where other health insurance information exists in the Composite Health Care System pursuant to reference (ae).

4.* MTFs have adequately followed up on collections from insurance providers pursuant to reference (ae).

• * MTFs must correct deficiencies that they found in the TPCP during the compliance audits pursuant to reference (ae).

* NEW, added to upcoming revision of UBO Manual pursuant to ASD(HA) Memorandum, “Revision of Compliance Audit Requirements in the Department of Defense 6010.15-M, “Military Treatment Facility Uniform Business Office Manual, “ November 9, 2006” (Feb 27, 2008)

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Authorities

• Sections 6102 and 6401 of the Patient Protection and Affordable Care Act (PPACA) mandate that skilled nursing facilities (SNF), nursing facilities (NF), and other health care providers and suppliers enrolled in Medicare, Medicaid, and the Children's Health Insurance Program adopt compliance programs as a condition of enrollment by March 23, 2013– Department of Health and Human Services has not yet

promulgated regulations. In the interim, may still look to the HHS Office of Inspector General (OIG) Compliance Program Guidance (similar to DHA UBO program)

– The OIG's voluntary compliance program guidance documents available at https://oig.hhs.gov/compliance/compliance-guidance/index.asp.

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Minimum Program Requirements

• Written policies and procedures– including standards of conduct to validate compliance commitment

• Compliance professional– not the UBO Manager, should have direct access to MTF Executive

Committee• Effective training

– regular, complete and documented programs with periodic updates• Effective communication

– encourage feedback, communicate non-retaliation, be visible• Internal monitoring

– audits and other evaluation techniques to monitor compliance• Enforce your standards

– wide publication of standards, reporting and disciplinary guidelines• Promptly respond to issues

– respond to alleged offenses and develop corrective action initiatives

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Roles and Responsibilities

• Compliance Officer (CO)– Oversees/monitors execution of compliance program – Ensures components of compliance program are executed– Communicates compliance program & coding/billing policies & procedures

• Compliance Committee– Advises CO and aids in execution of compliance program – Monitors internal program controls– Ensures periodic audits are performed– Ensures implementation of internal fiscal/administrative controls

• MTF personnel– should review their specific Compliance Audit Checklist and worksheets to

understand their program’s audit requirements– Provide UBO CO with requested audit information– must correct any errors or deficiencies identified during audit– Attend trainings, ask questions and report discrepancies

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DHA Compliance Audit Toolkit

• Available on the DHA UBO website at http://www.tricare.mil/ocfo/mcfs/ubo/policy_guidance/letters.cfm – Anti-Fraud Program at Military Treatment Facilities (MTFs) – Compliance Plan Implementation Policy– Code of Conduct– Certification Memo– Sample Compliance Committee Charter– TPCP Claim Post-Submission Review Worksheet – MSA Claim Post-Submission Review Worksheet – MAC Claim Post-Submission Review Worksheet – Compliance Audit Checklist – Annual Review of Compliance Program Effectiveness Checklist– Model Compliance Document

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Changes to Checklist

• General Compliance

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Changes to Checklist, cont.

• General Compliance

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Changes to Checklist, cont.

• Internal Management Control

• Coding Compliance

• Insurance Billing

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Changes to Checklist, cont.

• TPCP

• Medicare, Medicaid and Civilian Emergency Patients

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Changes to ChecklistElective Cosmetic Surgery

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Changes to ChecklistElective Cosmetic Surgery

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Changes to TPCP ClaimPost Submission Works

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Checklist Highlights

• Is the compliance plan/program reviewed/validated by the UBO Compliance Officer at least annually?

• Are audit deficiencies identified by agencies external to the MTF (AAA, DoD IG, etc.) addressed and corrected?

• Are the current inpatient ASA rate, Family Member Rate (FMR), Hospital/Professional percentages, Medicare Inpatient Deductible and Food Service (subsistence) rates loaded in CHCS? – Who performs this task? – Who ensures this task was completed and correct?

• Do you meet regularly with the Coding Compliance Office?• Is there communication/coordination between the UBO and: – Coding Staff; – Data Quality Manager (or equivalent) on coding issues?

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Checklist Highlights, cont.

• Does the UBO Manager review the monthly DQ statement for information pertinent to the DD Form 2569?

• Is there a process to forward insurance information (e.g., DD Form 2569) related to civilian emergencies to the MSA office?

• Is a sampling of bills reviewed by someone other than the biller prior to submission to validate accuracy?

• Are claims denied due to coding: researched; tracked; appealed? • Are pay-patients alerted to their financial responsibility for

healthcare services furnished by the MTF, including pharmacy charges?

• How often are unannounced cash counts being conducted? • Are there adequate procedures for accepting and securing funds and

valuables into the MTF after normal duty hours? • Is the appropriate patient deposit record form completed for each

patient whether or not a deposit is made?

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Checklist Highlights, cont.

• Are civilian emergency patients interviewed, and is an appropriate insurance authorization and release of medical information form signed by the patient?

• Are Medicare-eligible civilian emergency patients billed at the appropriate rate?

• Is the state Medicaid program billed for emergency, Medicaid-eligible patients?

• Is there an MTF process to register designees into CHCS with complete demographic information, if needed, for billing purposes?

• Are copies of designee letters maintained on file in the MSA office? • Are there processes to identify/track foreign military accounts and

to obtain medical insurance policy information? • Is appropriate documentation (ITOs) being presented to the MSAO

prior to treatment?

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Checklist Highlights, cont.

• Are all patients required to pay for their elective cosmetic surgery procedures in advance of the procedures?

• Are all patients requesting/receiving elective cosmetic surgery beneficiaries of the MHS?

• Is the current version of the cosmetic surgery estimator (CSE) being used IAW issued guidance?

• Are all MAC services in the MAC Enhancement Module forwarded to the Legal office for review?

• Does your legal authority overseeing medical care recovery instruct you as to which encounters to generate MAC bills for?

• Does the UBO furnish claims forms with accurate/correct cost computations to the appropriate office?

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Billing Risk Areas

• Using improper DoD billing rates • Outpatient Itemized rates versus inter-agency • Up-coding/unbundling

– Changing procedure codes to bill at a higher rate – Inaccurate evaluation and management codes for a higher intensity

or level of care than provided• Charging services without appropriate documentation or substantiation • Billing for services without an established rate • Billing clinic visits as same day surgeries (APVs)• Billing for services not rendered or documented• Billing Medicare for other than civilian emergencies• Accepting overpayments from payers without DHA authorization• Commingling TPC and MSA funds• Destroying claim documentation or accounts receivables

– 6-year, 3-month statute of limitations

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Billing Risk Areas, cont.

• Failing to execute or follow marginal internal fiscal controls– Separation of duties (e.g., creating & submitting bills, posting,

logging, and depositing checks, making entries to financial reports– Reconciling accounting records

• Failing to record receivables/checks/payments accurately and promptly• Failing to reconcile financial records

– Invoices (DD7/7A), receipts & cash collection vouchers DD Form 1131– Reports of program results DD Form 2570– Daily activity logs– Monthly MSA reports

• Inadequate audit trail of financial receipts– Concealing improper billing practices

• Impeding investigations– MTF administration overlooking, disregarding, defending, or

affirmatively concealing the MTF's illegal billing practices

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Determining Effectiveness

• Policies must be implemented• Achieve desired results• Updated appropriately• Enforced • Messaged from top-down • Culture reflects requirements and standards• Finding problems early before large impact• Decrease in beneficiary complaints• Increased payer reimbursement• Effective resolution of problems – compliance issues not recurring• Data analysis is detecting fraud, waste and abuse

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Ineffective Compliance Practices

• Policies not updated regularly• Governing body does not review/approve• No compliance message from leadership• Contractors, Volunteers, temporary staff, etc. do not receive

requirements and standards• Employees unfamiliar with requirements and standards

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Responding to Alleged Offenses

• DoD and Service-specific procedures– Investigate alleged noncompliance, violations of applicable

federal laws, or other types of misconduct in accordance with established federal guidelines

– Promptly report offenses to the appropriate authorities in accordance with established Federal guidelines

– Send copies of all reports, and subsequent actions taken, to the UBO Service Program Manager

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Challenges to Making it Work

• Program cannot be successful without support of MTF Commander– Keep your leadership informed to keep them engaged

• Difficult to get entire MTF to follow the rules– Continual facility training keeps MTFs up to date

• Current systems don’t have required capability needed– Maintain a good working rapport with your IT office to ensure

your programs get the upgrades they need• Other compliance programs and regulations already audit some

areas of the revenue cycle– Work smarter not harder: work with the other areas to

collaborate & compile information

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In Conclusion

• Become an expert in billing, coding laws, and policies• Understand best practices for healthcare compliance• Be aware of the billing risk areas in MTFs• Effective ongoing monitoring is necessary (e.g., committee

meetings)• Focus organization toward meeting compliance goals – team effort

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Thank You

Questions?

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Resources

• Compliance resources– DHA Office of Program Integrity– HHS OIG (model plans)

• MTF policies and procedures in addition to DHA UBO toolkit (slide 14)– 1000.24 – Confiscation of Fraudulent Identification (ID) Cards at Military Treatment

Facilities– DoDI 5505.12 – Anti-Fraud Program at MTFs– DoDD 6040.41 – Medical Records Retention and Coding at Military Treatment

Facilities Care Programs– DoDI 6015.23 – Delivery of Healthcare at Military Treatment Facilities (MTFs)– DoD 6010.15-M – Military Treatment Facility Uniform Business Office (UBO)

Manual– DoDD 5400.11 – DoD Privacy Program– DoD 5400.11-R – DoD Privacy Program (Manual)– DoDD 6025.18 – Privacy of Individually Identifiable Health Information in DoD

Health Care Programs– DoD 6025-18-R – Privacy of Individually Identifiable Health Information in DoD

Health Care Programs (Manual)

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Instructions for CEU Credit

This in-service webinar has been approved by the American Academy of Professional Coders (AAPC) for 1.0 Continuing Education Unit (CEU) credit for DoD personnel (.mil address required). Granting of this approval in no way constitutes endorsement by the AAPC of the program, content or the program sponsor. There is no charge for this credit.

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