A D V A N C E D T R A I N I N G S O L U T I O N S
A Closer Look at our Compliance Training Courses
includes scenarios, case studies, healthcare compliance examples, and course-ware testing.
General Compliance: Fraud & Abuse, HIPAA and EMTALA Basics
(Customizable)
Compliance Topics:
Elements of an Effective Compliance Program
Defining Fraud & Abuse
False Claims Act
Stark Law
HIPAA-Privacy Protections
HIPAA-De-Identification
HIPAA-Minimum Necessary Rule
HIPAA-Security Best Practices
Overview of EMTALA
EMTALA Requirements
Entities Affected by EMTALA
Understanding the Elements
Preventing Fraud & Abuse
Anti-Kickback Statute
HIPAA
HIPAA-Protected Health Information (PHI)
HIPAA-Treatment, Payment & Operations
HIPAA-Incidental Disclosures
HIPAA-Breach Notification
EMTALA Definitions
Patient Selection & EMTALA Violations
When Does EMTALA End
Compliance Program Requirements for the Board
(Customizable)
Compliance Topics:
Why Have a Compliance Program
Defining Fraud & Abuse
Individual Accountability for Compliance Wrongdoing
Board Oversight
Board Oversight-Duty of Care
Board Oversight-Benchmarks
Effective Compliance Program Elements
Fraud & Abuse Laws
Board’s Role in Compliance
The Caremark Case
Board Oversight-Good Faith
Board Oversight-Roles & Responsibilities
Fraud & Abuse Level 1: General Staff
(Customizable)
Fraud and Abuse Compliance Topics:
Fraud Key Points
Key Points: Documentation
Key Points: False Claims Act
Key Points: Stark Law
Abuse Key Points
Key Points: Record Retention
Key Points: Anti-Kickback Statute
Key Points: Reporting
Fraud & Abuse Level 2: Management & Physicians
(Customizable)
This course is divided into sections
Section 1: Value & Ethics
Section 2: Fraud & Abuse
Section 3: Conflict of Interest
Section 4: Enforcement, Agencies & Initiatives
Section 5: Compliance Programs
Section 6: Management Responsibilities
Section 1: Value and Ethics Compliance Topics:
Compliance responsibilities
Section 2: Fraud and Abuse Compliance Topics:
Fraud
Prevention of Fraud
Abuse
Prevention of Abuse
Key Points: Fraud & Abuse
State False Claims Acts
False Claims Act (FCA)
Key Points: False Claims Act
Anti-Kickback Statute
Anti-Kickback Statute: Safe Harbors
Anti-Kickback Statute: Penalties
Stark Law
Stark Law: Penalties
Section 3: Conflict of Interest Compliance Topics:
Conflict of Interest (COIs)
EMTALA
Key Points: EMTALA
Voluntary Refunds and Self-Disclosures
Voluntary Refunds and Self Disclosures: Potential Remedies
Employee Reporting of Regulatory Violations
Section 4: Enforcement Agencies & Initiatives Compliance Topics:
Enforcement Agencies
The Center for Medicare & Medicaid Services (CMS)
Office of Inspector General (OIG)
Office of Civil Rights (OCR)
US Department of Justice (DOJ)
State Medicaid OIG and Fraud Control Units
Health Care Fraud Prevention & Enforcement Action Team (“HEAT”)
Enforcement Initiatives: OIG Work Plan
“RAC”, “CERT”, “ZPICS” and “MIC’s”
Section 5: Compliance Programs Compliance Topics:
The Role of Compliance Program
Compliance Programs and OIG
Benefits of an Effective Compliance Program
Your Role in Compliance
Elements of an Effective Compliance Program:
Element 1: Policies & Procedures
Element 2: Oversight Responsibility and Governance
Element 3: Training & Education
Element 4: Lines of Communication
Element 5: Monitoring & Auditing
Element 6: Enforcement & Discipline
Element 7: Response & Prevention
Section 6: Management Responsibilities Compliance Topics:
Management Responsibilities & Duties
Fraud & Abuse Level 3: High Risk Areas
(Customizable)
This course is divided into sections:
Section 1: Value & Ethics
Section 2: Fraud & Abuse
Section 3: Conflict of Interest
Section 4: Enforcement, Agencies & Initiatives
Section 5: High Risk Areas
Section 6: Compliance Programs
Section 1: Value and Ethics Compliance Topics:
Compliance Values and Ethics
Section 2: Fraud and Abuse Compliance Topics:
Fraud
Prevention of Fraud
Abuse
Prevention of Abuse
Key Points: Fraud & Abuse
False Claims Act (FCA)
The Affordable Care Act (ACA)
Could a False Claim Exist
Billing for Services Not Provided
Billing for Services Not Documented
Unbundling
Upcoding
Falsifying Statements
Failure to Refund Overpayments
Duplicate Billing
Admissions
Billing the Wrong Units for a Particular Medication
State False Claims Act
Key Points: False Claims Act
Qui Tam Provisions
Key Points: Anti-Kickback Statute
Anti-Kickback Statute
Anti-Kickback Statute: Safe Harbors
Anti-Kickback Statute: Penalties
Stark Law
Stark Law: Penalties
Section 3: Conflict of Interest Compliance Topics:
Conflict of Interest (COIs)
Voluntary Refunds or Self-Disclosures
Voluntary Refunds and Self-Disclosures: Potential Remedies
Employee Reporting of Regulatory Violations
Section 4: Enforcement Agencies & Initiatives Compliance Topics:
Enforcement Agencies
The Center for Medicare & Medicaid Services (CMS)
Office of Inspector General (OIG)
Office of Civil Rights (OCR)
US Department of Justice (DOJ)
State Medicaid OIG and Fraud Control Units
Health Care Fraud Prevention & Enforcement Action Team (“HEAT”)
Enforcement Initiatives: OIG Work Plan
Enforcement Initiatives: RACs, CERT, ZPICs, MICs
Non-Governmental Payor Audit Initiatives
Section 5: High Risk Areas Compliance Topics:
Documentation
Documentation Requirements
Coding & Billing
Coding & Billing: Medical Necessity
Medicare Coverage Requirements
Finance
Section 6: Compliance Programs Compliance Topics:
The Role of a Compliance Program
Compliance Programs and OIG
Benefits of an Effective Compliance Program
Elements of An Effective Compliance Program:
Element 1: Policies & Procedures
Element 2: Oversight Responsibilities
Element 3: Training & Education
Element 4: Lines of Communication
Element 5: Monitoring & Auditing
Element 6: Enforcement & Discipline
Element 7: Response & Prevention
Effective Compliance Program
Patient Relationships and Compliance
(Customizable)
Compliance Topics:
Promoting Good Patient Relationships
Developing Patient Trust
Providing Good Service
Handling Patient Complaints
Increasing Awareness of Recurring Issues
Resolving a Complaint
Resolving a Complaint
Complaints & Associated Risks
Admissions & Registration 1: Collecting Patient Demographics
(Customizable)
Compliance Topics:
Patient Registration Compliance
Collecting Patient Demographics
Collecting Patient Demographics-
Inaccurate Information
Obtaining Insurance Information
Contacting the Insurance Company
Co-Payments & Deductibles
Validating Medical Record Numbers
Financial Hardship & Waiver of
Co-payments/Deductibles
Medical Record Number-Compliance
and Monitoring
Registering Patients Receiving
Ancillary Services
Ancillary Services Registration-Additional Forms
Identity Theft Protection Policy
Identifying Suspicious Activity
Detecting & Responding to Potential
Identity Theft
The Birthday Rule
Admissions & Registration 2: ABNs and MSPs
(Customizable)
Compliance Topics:
ABN Overview
ABN Requirements
ABN Forms
Other ABN Forms
Completing the ABN
Completed ABNs
Services Never Covered by Medicare
Notices of Exclusion from Medicare Benefits
Statutorily Excluded Services
Medically Unnecessary Services
Screening Services
Medicare as Secondary Payer (MSP)
MSP Compliance
Examples of Medicare as Secondary Payer
MSP Exceptions
When ABNs are Appropriate
ABN Scenarios
Obtaining ABNs in the Emergency Department
Obtaining Signatures
Patient Options
Patient Options-Choices
Patient Options-Exceptions
Admissions & Registration 3: Observation Services, HIPAA and Other Compliance Risk
(Customizable)
Compliance Topics:
Observation Services
Observation Services-Exclusions/Examples
Registering Observation Services
Changing an Inpatient to Observation Services
Observation Services- Cases
Over 24 hours
The 2-Midnight Rule
HIPAA Overview
Notice of Observation
Invalid Ordering/Referring Providers
HIPAA’s Effect on Registration
HIPAA & Confidentiality
Other Compliance Risks
Investigational & Research Procedures & ABN
ER Patients/EMTALA
Definition of Emergency Department
Registration & EMTALA
Patient Orders
Standing Orders
Items to List on Standing Orders
Retention of Orders/Referrals
Handling Standing Orders that have Expired
Allied Health Services 1: Medical Necessity
(Customizable)
Compliance Topics:
Observation Services
Medical Necessity
Medical Necessity Guidelines
National Coverage Determination
National Coverage Determination Examples
Local Coverage Determinations
Local Coverage Determination Examples
Diagnosis Coding
Requirements to Furnish Diagnostic Information
Allied Health Services 2: Covered and Non-Covered Services
(Customizable)
Compliance Topics:
Advance Beneficiary Notices
Advance Beneficiary Notice Requirements
Non-Covered Services
Screening Services
ABN Forms
Other Financial Responsibility Forms
When ABNs are Appropriate
ABN Scenarios
Patient Options
Patient Options-Choices
Patient Options-Exceptions
Obtaining ABNs in the Emergency Department
Allied Health Services 3: Processing Orders
(Customizable)
Compliance Topics:
Processing Orders
Authorized Providers
Invalid Ordering/Referring Providers
Retention of Orders/Referrals
Verbal/Telephone Orders
Verbal/Telephone Orders-Timeframes
Medicare 3-Day (1-Day) Payment Window Policy
Services Ordered & Performed
Charge Capture Process
Unclear Orders
Unclear Orders-Documentation
Allied Health Services 4: Billing Compliance
(Customizable)
Compliance Topics:
Billing Compliance-Overview
Separately Billable Supplies
Separately Billable Supplies-Ambulatory Payment Classification
Unbundling of Multiple Procedures & Examples
Duplicate Orders
Duplicate Orders-OIG Investigations
Charge Master Description
Changes to the Charge Master Description
The Department’s Role in HCPCS Code Assignment
Modifiers & Examples
Investigational and Research Use Only Procedures
Consistency of Charges & Examples
Discount Policies
Allied Health Services 5: Cardiology
(Customizable)
Compliance Topics:
Observation Services
Observation: Physical Evaluation
Observation Services: Start/Stop Times
Payment for Observation Services
Reporting Observation Services
Treatment Room Charges
Contrast Materials
Charging for Contrast Materials
Cardiac Catheterization
Cardiac Catheterization: Documentation
Cardiac Catheterization: Injection Procedures
Electrophysiology
Electrophysiology: Coding & Documentation
Interventional Procedures
Cardiac Rehabilitation
Cardiac Rehabilitation: Participation
Coverage Conditions for Cardiac Rehabilitation
Notice of Observation
2-Midnight Rule
Allied Health Services 6: Dialysis
(Customizable)
Compliance Topics:
Dialysis Services
ESRD Medicare Entitlement
Medicare Eligibility
ESRD Evidence Report
ESRD Medical Evidence Report: Completion
ESRD Initiatives Quality Reporting
ESRD Prospective Payment System (“PPS”
Home Dialysis Payment Method
Home Dialysis Support Services
Partial Month Services
Erythropoiesis Stimulating Agents
Renal Dialysis Services ESRD Drug Categories
ESRD Laboratory Testing
Standing Orders
Items to List on Standing Orders
Handling Expired Standing Orders
Allied Health Services 7: Radiology
(Customizable)
Compliance Topics:
Contrast Material
Charging for Contrast Materials
Interventional Radiology
Interventional Radiology: S & I
Mammography
Mammography: Frequency of Screenings
Mammography: Charging for Services
Identifying & Charging for Mammography
Skilled Nursing Facilities
Skilled Nursing Facilities: OIG
Skilled Nursing Facilities: Discounts
Education Programs
Education Programs: Oversight
Professional Fees
Professional Fees: Billing
Professional Fees: Compliance
Portable X-Ray Services & Regulatory Updates
Portable X-Ray Services: Separate Billing
Allied Health Rehabilitative Therapies 1: Therapy Care
(Customizable)
Compliance Topics:
Medicare Part A
Medicare Part B
Medical Necessity
Medicare & Medical Necessity
CMS
Office of Inspector General (OIG)
OIG Work Plan
Physician Certification/Re-Certification
Provider Roles
Certification
Completion of Certification
Re-Certification
Durable Medical Equipment
Treatment Notes
DMEPOS & Certificate of Medical Necessity
Documentation Requirements
Initial Evaluation, Re-evaluation and Plan of Care
Skilled Therapy Maintenance Programs
Progress Reports
Progress Report Elements
Reasonable & Necessary: Skilled Therapy Maintenance Programs
Allied Health Rehabilitative Therapies 9: Coding & Billing
(Customizable)
Compliance Topics:
Code Pair Edits
Time-Based Therapy Services
Modifiers
Validating Charges
Pre-billing Audits
Group Therapy Services
Group Therapy Requirements
Individual vs. Group Therapy Services
Therapy Caps
Therapy Caps-Exceptions
Students, Assistants and Aides
Billing Services Provided by Students/Aides
Supervision and Billing
Certification of Foreign-Born Therapists
Certification of Foreign-Born Therapists
Other Therapy Billing Issues
HIM Coding Compliance 1: General Coding Issues
(Customizable)
Compliance Topics:
Medical Necessity
Services Not Covered Under Medicare
Screening Services
Medical Necessity Software
Up-coding
Physician Query Process
Query Format and Response
HIM Coding Compliance 2: Inpatient/Outpatient Coding
(Customizable)
Compliance Topics:
Inpatient Coding
Inpatient Diagnoses Coding
Consequences of Improper Coding
Discharge/Transfer Status Codes
Discharge/Transfer MS-DRGs
Identifying Proper Discharge Codes
Identifying Proper Transfer Codes
Compliance & Discharge/Transfer Codes
Problematic DRGs
Outpatient Procedure Coding & Examples
Outpatient Diagnosis Coding
Outpatient Diagnostic Guidelines
Outpatient Diagnosis Coding-Applying ICD-10-CM Rules
Outpatient Documentation Guidelines
HIM Coding Compliance 3: Coder Education and Ethics
(Customizable)
Compliance Topics:
OIG Requirements
Education Methods
Coder Training
Coding Credentials
AHIMA Standards for Ethical Coding
Government Resources
Coding Resources
Coder Feedback
HIM Compliance Management 1: An Effective Compliance Program
(Customizable)
Compliance Topics:
HIM Responsibilities
Effective Compliance Program: Overview
Element 1: Policies and Procedures
Policies and Procedures: Routine Reviews
Element 2: Oversight
Oversight: HIM Management Responsibilities
Element 3: Training and Education
Education Topics
Element 4: Communications
Anonymous Reporting Methods
Element 5: Disciplinary Policy and Action
Disciplinary Action and Employee Screening
Element 6: Auditing and Monitoring
Auditing and Monitoring Activities
Element 7: Problem Resolution and Corrective Actions
Developing Corrective Actions
HIM Compliance Management 2: HIM Compliance Policies
(Customizable)
Compliance Topics:
Documentation: Policies & Procedures
Documentation: Minimum Requirements
Documentation: Code Assignment
Quality Improvement Organizations
Proper Selection and Sequencing of Diagnosis
ICD-10-CM Coding
Coding Guidelines
Professional Organizational Agencies
Coding Resources
Chargemaster: Updates
Chargemaster: Coordination
Coder Incentives
Chargemaster Updates: Coordination
Service Contracts
Appropriate Coding Incentives
Service Contracts: Contractor Incentives
HIM Compliance Management 3: Coding Quality Reviews
(Customizable)
Compliance Topics:
Coding Quality Reviews
Internal Reviews
External Reviews
Pre-billing Reviews
Rebilling Policies
Tracking Rebilled Claims
Random vs. Focused Samples
Focused Selection of Records
Random Selection of Records
Audit Trends
Audit Trends: Benefits
Comparative Statistics
Analyzing Trends: Case Mix
OIG Work Plan
PEPPER
PEPPER Data and Outliers
PEPPER Focused Audits
Reporting Quality Review Activities
Coding Error Patterns
National Correct Coding Initiatives
CCI-Examples
HIM General Compliance 1: Regulatory Environment
(Customizable)
Compliance Topics:
Regulatory Environment
Federal Agencies
Conditions of Participation
Conditions of Participation Updates
Quality Assessment Performance Improvement
State Agencies
Voluntary Accreditation Programs
HIM and Accreditation
HIPAA
HIPAA and Confidentiality
Recovery Audit Program
Physicians at Teaching Hospitals (PATH) Audits
Teaching Physician Documentation
Electronic Signature Requirements
HIM General Compliance 2: HIM Practice Implications
(Customizable)
Compliance Topics:
Practice Implications
Differences in Requirements
Joint Commission
Health Information
Medical Record Review
Managing Delinquent Records
Delinquent Records Levels of Compliance
Joint Commission Updates
Unannounced Surveys
Patient Safety Goals
Tracer Methodology
Release of Information
Confidentiality
Release of Information-Special Circumstances
Late Entries, Addenda and Correction to the Medical Record
Patient Requested Amendments
Duplicate/Overlay Medical Record Numbers
Medical Record Number Monitoring
Nursing Documentation 1: Medical Necessity, Forms, and ABNs
(Customizable)
.
Compliance Topics:
Medical Necessity
Medical Necessity-Requirements
Advance Beneficiary Notice (ABN)
When ABNs are Appropriate
Medicare Guidelines
Non-Covered Services
Screening Services
Obtaining Signatures
Patient Refusals
Types of ABN Forms
Completing the ABN
Obtaining ABNs in the ER
Nursing Documentation 2: Documentation & Orders
(Customizable)
Compliance Topics:
General Principles of Documentation
Primary Use of the Medical Record
Abbreviations
Authentication of Entries
Late Entrie
Late Entries-Paper & EMR
HIPAA-Changes to the Medical Record
OIG Documentation Requirements
Other Important Documentation
Post Payment Documentation Reviews
Consequences of Incomplete/Inaccurate/Documentation
Verbal/Telephone Orders
Verbal Orders
Verbal Order Requirements
Verification of Physician Orders
Services Without Orders
Nursing Documentation 3: Rules, Regulations, Laws and Statutes
(Customizable)
Compliance Topics:
HIPAA and Confidentiality
Protected Health Information (PHI)
Medical Records
Authorizations & Authorization Forms
Confidentiality & Release of Information
Review- Stark Law & Anti-Kickback Statute
Stark Laws Overview
Exceptions to the Stark Law
Anti-Kickback Statute
Vendor Gifts & the Anti-Kickback Statute
Patient Gifts and the Anti-Kickback Statute
Related Entities & Freedom of Choice
EMTALA Overview
EMTALA Registration
Nursing Documentation 4: Other Compliance Topics
(Customizable)
Compliance Topics:
Ongoing Assessment-Medical Necessity
Ongoing Assessment-Timely Communications
Outpatient Observation Services
Documenting Observation Services
Observation Orders/Cases Exclusions
Observation-Physical Evaluation
Admitting a Patient from Observation
Observation Services vs. Admission
Observation Services
Changing Observation Status
Observation Services: Start/Stop Times
Reporting Observation Services
Observation Time Over 24 Hours
Improper Admission from Observation
Payment for Observation Services
Admission Status-Important Decision
The 2-Midnight Rule
Three-Day Outpatient Payment Window Rule
Three-Day Outpatient Payment Window-Exceptions Unused Medication-Overview
Services Provided by Non-Nursing Personnel-Overview
Skilled Nursing 1: 3-Day Prior Hospitalization
(Customizable)
Compliance Topics:
Review of Regulatory Requirements
Verification of Compliance
Consequences of Non-Compliance
Skilled Nursing 2: Medical Necessity & Utilization Review
(Customizable)
Compliance Topics:
What is Necessary for Coverage in a SNF
Medicare Reimbursement for SNF
Skilled Services
Skilled Nursing Services
Skilled Rehabilitation Services
Documentation of Skilled Services
Verification of Benefits/MSP/Assignment of Benefits
Physician Certification/Re-certification
Skilled Nursing 3: MDS, Billing and Reimbursement
(Customizable)
Compliance Topics:
Review of Regulatory Requirements
MDS as a Reimbursement Tool
MDS and its Relation to Billing
Change of Condition
Co-payments & Deductibles
Consolidated Billing & Examples
Skilled Nursing 4: Patient Care Issues
(Customizable)
Compliance Topics:
Quality of Care-OIG Guidelines
Residents Rights & Examples
Ongoing Assessment
Skilled Nursing 5: Other Compliance Issues
(Customizable)
Compliance Topics:
Documentation-General Principles
Referral Relationships & Requirements
Documentation-Physician Visits
Hospice & Skilled Nursing
Medicare Part D
Patient Financial Services 1: General Compliance
(Customizable)
Compliance Topics:
Medical Necessity
Non-Covered Services-Scenario
Statutorily Excluded Services
Medically Unnecessary Services
Obtaining ABNs in the ER
Non-Covered Services: ABNs & HINNs
Screening Services
Patient Options
ABN Forms
When ABNs are Appropriate
Patient Options: Exceptions
Facility Options: Choices
Examples of Medical Unnecessary Services
Advanced Beneficiary Notices (ABNs)
Promoting Compliance: Medical Necessity Guidelines
Advanced Beneficiary Notices and PFS
Advanced Beneficiary Notice Requirements
Other Financial Responsibility Forms
Patient Financial Services 2: Claims Processing
(Customizable)
Compliance Topics:
Medicare as Secondary Payer (MSP)
MSP Compliance
MSP Exceptions
Discharge/Transfer
Discharge/Transfer Compliance
Charge Description Master
CDM Updates
Unbundling/Examples
Observation Services
Observation: Physician Evaluation
Observation Services: Start/Stop Times
Payment for Observation Services
Reporting Observation Services
Observation Orders
3-Day (or 1-Day) Payment Window Rule
Changing Inpatient Status to Observation
End Stage Renal Disease
Investigational & Research Procedures
Exceptions: Clinical Trial Services
Ambulance Services
Ambulance Services: Medical Necessity
HIPAA
Notice of Observation
Patient Financial Services 3: Claims Submission
(Customizable)
Compliance Topics:
Systems Integrity
Implementation on the NPI
Claims Editing
Holding Claims
Claims Editing: UB-04 Form
Claims Editing: Policies & Procedures
Duplicate Charges
Duplicate Claims
Return to Provider Reports
Return to Provider Reports
Rebilling/Resubmission
Electronic Claims
Electronic Billing Integrity & Examples
Patient Financial Services 4: Payments & Refunds
(Customizable)
Compliance Topics:
Contractual Adjustments & Allowances
Contractual Adjustments- Patient Billing
Denials
Communication of Errors
Appeals
Duplicate Charges
Medicare Credit Balance Reporting
Credit Balances-Policies & Procedures
Bad Debt
Processing Bad Debt
Write-Offs & Examples
Administrative Write-Offs
Waiver of Coinsurance & Deductibles
Write-Offs and Compliance
Adjustments-Documentation
Charity/Free Care
APC Reimbursement
Determining APC Payment Amounts
Cost Report-Overview
Cost Report-Implications
Causes of an Inaccurate Cost Report
Repayment of Overpayments
Laboratory Administration 1: CLIA Certification
(Customizable)
Compliance Topics:
Types of Laboratory Testing
Waived Testing
Non-Waived Testing
Who Needs a CLIA Certificate
Types of CLIA Certificates
Application for Certification
CLIA Exemption
Maintaining a CLIA Certificate
Proficiency Testing
Proficiency Testing Requirements
Inspection Process
Testing Locations
CLIA and Billing Laboratory Tests
Other Exceptions
Laboratory Administration 2: Laboratory Compliance Issues
(Customizable)
Compliance Topics:
Requisition Design
OIG Recommendations for Requisitions
Notice to Physicians
Ordering Tests Not Listed on the Requisition
Test Utilization & Monitoring
Reasons for Change in Test Volume
Provisions of Equipment and Supplies
Duties for “On-Site” Laboratory Employees
Other Opportunities to Communicate
Laboratory Administration 3: General Compliance Issues
(Customizable)
Compliance Topics:
Stark Law
Record Retention
Record Retention and Compliance
Negotiated Rulemaking Standards for Records
Contacting Physicians for Information
HIPAA Overview
Confidentiality in the Laboratory
Direct vs. Indirect Treatment Relationship
Laboratory Outreach Programs
Regulatory Updates
Regulatory Considerations for Outreach Programs
Denials, Non-Payments & Appeals
Applicable Laws
Laboratory Coding & Pricing 1: Coding, Pricing and the CDM
(Customizable)
Compliance Topics:
HCPCS Codes (Level 1 & Level 2)
HCPCS Code Assignment
Revenue Codes
HCPCS & Screening Tests
HCPCS Code assignment and the Laboratory
Ad Hoc Updates
Pricing Overview
Modifiers
State Pricing Requirements
Chargemaster Review
Charge Description Master
Documenting Updates
Laboratory Coding & Pricing 2: Special Coding Situations
(Customizable)
Compliance Topics:
Organ & Disease Oriented Panels
Organ/Disease Panels & ESRD Testing
Custom Panels & Profiles
OIG Recommendations for Custom Profiles
Creating Custom Panels/Profiles
Panel Pricing
Miscellaneous Tests
Identification & Entry of Miscellaneous Tests
Reporting/Billing of Miscellaneous Tests
Miscellaneous In-House Tests
RUO/IUO Tests
Reporting RUO/IUO Tests
Billing RUO/IUO Tests
Processing Laboratory Orders 1: Registration & Receipt of Orders
(Customizable)
Compliance Topics:
Collecting Patient Registration Information
Additional Patient Registration Information
Patient Registration Forms
Patient Registration Forms- Medicare Secondary Payer
MSP and the Laboratory
Date of Collection-Clinical Laboratory Tests
Date of Collection- Stored Specimen Exceptions
Requesting/Ordering Provider Information
Exclusion from Participation
Provider Identification
Invalid Ordering/Referring Providers
Consequences of Listing the Wrong Ordering Provider
Retention of Orders/Referrals
Administrative Simplification Requirements
National Provider Identification
Processing Laboratory Orders 2: Types of Laboratory Test Orders
(Customizable)
.
Compliance Topics:
Unclear Orders
Unclear Orders-Documentation
Standing Orders
Items to List on Standing Orders
Verbal Orders
Handling Standing Orders-Expired
Billing Considerations with Verbal Orders
Duplicate Orders & Examples
Avoiding Duplicate Billing Situations
Duplicate Billing
Processing Laboratory Orders 3: Processing Orders
(Customizable)
Compliance Topics:
Bundling of Laboratory Services
Consequences of Unbundling Services
Examples of Unbundling of Orders
Three-Day Outpatient Payment Window Rule
Three-day Window – Lab Services
Specimen Collection Fees
Specimen Collection Fees – Separate Payment
When Specimen Collection Fees May Not Be Charged
Travel Allowances
Reflex/Confirmatory Testing
Criteria for Reflex/Confirmatory Testing
Medical Necessity
Testing Ordered & Performed
STAT Tests & Handling Charges
Billing for Calculations & QC Tests
Laboratory General Compliance 1: Medical Necessity
(Customizable)
Compliance Topics:
Medical Necessity
Establishing Medical Necessity
Payment & Medical Necessity
Coverage Determinations
Staff’s Role & Medical Necessity
Medical Necessity-Exclusions & Exceptions
Non-covered Services
Requirement to Furnish Diagnostic Information
Obtaining Diagnostic Information
Diagnosis Coding
Advanced Beneficiary Notice
ABN Forms
When an ABN should be Obtained
Completing the ABN
Modifying ABNs
Obtaining ABN’s in the Emergency Department
Obtaining ABN’s After Receipt of the Specimen
Patient Options
Patient Options-Exceptions
Laboratory General Compliance 2: Other Compliance Topics
(Customizable)
.
Compliance Topics:
Direct Billing Requirement
State Requirements for Direct Billing
Direct Billing & Hospital Laboratories
Hospital Laboratories and APC’s
Discount Policies
Discount Policies-Documentation
End Stage Renal Disease (ESRD) Testing
Testing for SNF Patients
Who to Bill for Tests Performed
Establishing Prices for SNF Services
OIG, Laboratories & SNF Testing
Point of Care Testing
Charging for POC Testing
Home Medical Equipment 1: Eligibility Criteria
(Customizable)
Compliance Topics:
Definition of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
Reasonable and Necessary
Medical Necessity
Oxygen
Beds
Wheelchairs & PMDs
Enterals & Parenterals
Home Blood Glucose Monitors
Therapeutic Footwear
Home Medical Equipment 2: Documentation, Billing & Other Compliance Risks
(Customizable)
Compliance Topics:
Physician Orders
CMN & DIFs
Refills
Patient Options
Medical Necessity
Repairs & Maintenance
Equipment Replacement
Capped Rentals
Pre-billing Audit
Co-Pays, Deductibles & Refunds
Home Care 1: Regulatory Compliance
(Customizable)
Compliance Topics:
Compliance Roles
* Administrator
* Clinical Manager
* Field RN/Therapist/Case Manager
* Home Health Aide
* Performance Improvement Coordinator
* Business Office/Finance Staff
Medicare Administrative Contractors (MACs)
MACs: Audits and Reviews
Conditions of Participation (COPs)
Medicare Certification Surveys
Accreditation
Medicare Certification: Non-Compliance
State Licensure
HIPAA Overview
National Provider Identification
Regulatory Information
Reimbursement Regulations
Home Care 2: Billing Compliance
(Customizable)
Compliance Topics:
Admission Policies and Procedures
Patient Demographics
Patient Rights & Responsibilities
Verification of Benefits
Medicare as Secondary Payer (MSP)
MSP Compliance
Examples of Medicare as Secondary Payer
Additional Admission Forms
ABN-Overview
When ABNs are Appropriate
Change of Care Notice & NOMC: QIO Review
Patient Options
Processing Requests & Denials
Responding to ADRs & Denials
Claims Filing: Appeal Timelines
Claims Processing Compliance
Anti-Kickback Statute
Examples of the Anti-Kickback Statute
Routine Waiver of Co-payments & Deductibles
Stark Law
Examples of the Stark Law
Home Care 3: Documentation Guidelines
(Customizable)
Compliance Topics:
Reason for Documentation
Conditions of Participation (COP)
Effective Documentation
Authorized Providers
Verbal Orders
Verbal Orders-Timeframes
Unclear Orders
Unclear Orders-Documentation
Medical Necessity
National & Local Coverage Determination
Medical Necessity & Medicare Refunds
Subcontracted Services
Home Health 1: Eligibility for Medicare Home Health Services
(Customizable)
Compliance Topics:
Eligibility Criteria
Criteria #1: Homebound
Determining Patient’s Homebound Status
Criteria #2: Skilled Care and Qualifying Services
Skilled Care Staff
Criteria #3: Intermittent or Part Time
Intermittent Services
Criteria #4: Under the Care of a Physician
Patient Rights
Plan of Care Orders
Recertification Orders
Recertification Orders: Example
Steps for Verbal Recertification
Criteria #5: Reasonable and Necessary
Reasonable & Necessary Determination
Reasonable & Necessary: Examples
Non-Covered Home Services
Able and Willing Caregivers
Able and Willing Caregivers/Examples
Home Health 2: Home Health Documentation
(Customizable)
Compliance Topics:
Plan of Care
Plan of Care Documentation
OASIS
OASIS Tool
OASIS: Pitfalls
Completing the OASIS
Completing the OASIS: Exception
OASIS Submission Requirements
Clinical Notes
Clinical Notes: Effective Documentation
Home Health 3: Billing
(Customizable)
.
Compliance Topics:
PPS Overview
Low Utilization Payment Adjustment (LUPA)
PPS Payments
Bundled and Consolidated Home Health Services
Excluded Services
One Agency
Health Insurance Query for Home Health (HIGH)
Assisted Living Facility Residents
Plan of Care: Billing
Home Health Charge Entry Process: Coding
Examples of Adjusted HHRG Payments
Home Health Charge Entry Process: Patient Visits
Patient Visit Examples
Home Health Pre-Billing Audit
Home Health Pre-Billing: RAP
Home Health Pre-Billing Audit: End of Episode Claim
Claims Submission
Additional Development Request (ADR)
Home Health Accounts Receivable
Rebilling/Resubmission
Transfers
Partial Episode Payments (PEP)
Hospice 1: Eligibility Criteria for Hospice Services
(Customizable)
Compliance Topics:
Eligibility Criteria
Definition of Hospice Care
Terminal Status
Determining Terminality
Benefit Periods
Hospice Election
Changes to the Election
Hospice Revocation/Discharge
Discharge Planning
Interdisciplinary Group
Levels of Care (4)
Hospice 2: Documentation
(Customizable)
Documentation is an important part of receiving reimbursement for the services provided by the hospice agency. This course will review documentation requirements specific to hospice agencies regarding:
• The Plan of Care
• Clinical Notes
Compliance Topics:
Eligibility Criteria
The Plan of Care
Clinical Notes
Hospice 3: Billing
(Customizable)
Compliance Topics:
Levels of Care and the Daily (Per-Diem) Rate
Per-Diem Rate Services
Availability of Services
Hospice Pre-Billing Audits
Hospice Accounts Receivables
Hospice Claims Submissions
Hospice Denied Claims/Rebilling
Hospice Payments & Collections
Hospice 4: Compliance Risks
(Customizable)
There are several other risks that must be considered for hospice services. This course will focus on the following topics:
• Hospice Services in a Skilled Nursing Facility
• Hospice Services in an Assistant Living Facility
• Improper Incentives for Referrals
• Volunteers
• Underutilization
Compliance Topics:
Hospice Services in a Skilled Nursing Facility
Responsibilities for Hospices and SNFs/NHs
Hospice Specific Responsibilities
SNF/Nursing Home Specific Responsibilities
Improper Incentives for Referrals & Financial Incentives for Overuse
Hospice Services Provided in Assisted Living Facilities
Volunteers
Underutilization
Physician Coding & Documentation
(Customizable)
.
Compliance Topics:
History and/or Examination
Using Time to Select the Level of Service
New Patient Total Time
Established Patient Total Time
Documentation Tips When Using Time
Clinical Example of Using Time to Select the Level of Service
Using MDM to Select the Level of Service
Codes 99202, 99212 Straightforward MDM
Clinical Example of 99202, 99212 Level
Codes 99203, 99213 Low MDM
Clinical Example 99203, 99213 Level
Codes 99204, 99214 Moderate MDM
Clinical Example 99204, 99214 Level
Codes 99205, 99215 High MDM
Clinical Example 99205, 99215 Level
Clinical Example of Using MDM to Select the Level of Service
Documentation Tips When Using MDM
2021 Guidelines for Prolonged Services
Prolonged Services 99XXX
Table for Use of Code 99XXX
Clinical Example of Prolonged Services
Prolonged Services (99354-99355), (99202-99215)
Table for Use Prolonged Services (99354-99355), (99202-99215)
Clinical Example of Prolonged Services (Psychotherapy)
Prolonged Services (99356-99357)
Table for Use of Prolonged Services (99356-99357)
Clinical Example of Prolonged Services
Prolonged Services (99358-99359)
Table for Use of Prolonged Services (99358-99359)
Prolonged Services (99415-99416)
Table for Use Prolonged Services (99415-99416)
Summary of 2021 E/M Codes
Determining the Overall E&M Level of Service-Established Patient
Physician Documentation 1: ABNs
(Customizable)
Compliance Topics:
What is an ABN
ABN Requirements
Determining Whether an ABN is Required
Statutorily Excluded Items or Services
Obtaining an ABN in the Emergency Department
Using the ABN Form
Signing the ABN
Signed ABNs
Billing When ABN is Obtained
Physician Documentation 2: Non-Physician Practitioners
(Customizable)
Compliance Topics:
What is a Non-Physician Practitioner
NPP Supervision Requirements-Physician Assistants (PAs)
NPP Supervision Requirements-Nurse Practitioner (NPs)
NPP Scope of Practice
Incident-to and Services in Office/Clinic Setting
Detail of Incident-to Regulations
Split or Shared Services in Hospital Setting
Physician Documentation 3: Outpatient vs. Inpatient
(Customizable)
Compliance Topics:
Observation Status
Observation Services
Observation Examples
Observation-Payor Criteria
Documenting Observation Services
Observation Status Guidelines
The 2-Midnight Rule
Observation Services- Cases Over 24-Hours
Overview of Patient Notifications
Physician Documentation 4: Teaching Facilities
(Customizable)
.
Compliance Topics:
Teaching Facility Services
Primary Care Exception (PCE)
Moonlighting
Documenting E&M Services
Documentation Examples
Specialty Documentation Requirements
Specialty-Specific Guidelines-Anesthesia
Specialty Specific Guidelines-OB/GYN
Specialty-Specific Guidelines-Surgery
Specialty Specific Guidelines-Psychiatry
EMTALA: The Basics (Core Module)
(Customizable)
Compliance Topics:
Overview of EMTALA
Emergency Medical Condition Defined
Medical Screening Examination Defined
“Comes to the Emergency Department” Defined
Dedicated Emergency Department Defined
Hospital Property Defined
EMTALA Requirements
EMTALA and Registration
Medical Screening Examinations (MSEs)
Patient Selection and EMTALA Violations
Physician Scope of Privileges
Stabilization or Transfer of Patients
Entities Affected by EMTALA
Hospital Property: Examples
Dedicated Emergency Department (DED)
What is Considered a DED
What is Not Considered a DED
EMTALA Applicability to Requests for Care
Outpatient Services
EMTALA and Inpatient Services
When does EMTALA End
EMTALA: Combined Supplemental Module
(Customizable)
Compliance Topics:
EMTALA Definition of MSE
Providing the MSE
Who Provides the MSE
When is a MSE Provided
Why is a MSE Needed
How is an MSE Conducted
MSE Scenarios
Documenting the MSE
Stabilization & Transfer
Stabilization Definitions
Unstable Patients
Patients Refusing Emergency Treatment
Transfers
Appropriate Transfers
Acceptance of Transfers
Transfer Certification
Patient Request for Transfer
Documenting the MSE
Documentation for Patients Refusing Emergency Treatment
Transfer Certification
Documenting Patient Request for Transfer
Documenting Transfers
Transfer Summary Form
Transfer Summary Form: Common Pitfalls
Documenting On-call List
Required Signage
Central Log
Entities Affected by EMTALA
Provider-Based Status and EMTALA
What is Considered a DED
Who is Not Considered a DED
Hospital Property
Hospital Property: Examples
Off-Campus Departments
Ambulance Services
Non-Provider-Based Facilities
Physician Scope of Privileges
On-Call List
Physician On-Call Requirements
Additional On-Call Requirements
Consequences of On-Call Coverage
Use of Non-Physician Practitioners
CMS Interpretive Guidelines
Updating the On-Call Schedule
Sending Patients to the Physician’s Office
EMTALA Investigations
Sources of Allegations
Investigating Agency
Investigation: Record Review
Peer Review by CMS
Medical Review by CMS
Penalties and Enforcement
Fines and Other Penalties
Trends in Enforcement
EMTALA 1: Medical Screening Examination (Supplemental Module)
(Customizable)
Compliance Topics:
What is a MSE
EMTALA Definition of MSE
Providing the MSE
Who Provides the MSE
When is a MSE Provided
Why is a MSE Needed
How is an MSE Conducted
MSE Scenarios
Documenting the MSE
EMTALA 2: MSE Transfers & Stabilization (Supplemental Module)
(Customizable)
Compliance Topics:
Stabilization & Transfer
Stabilization Definitions
Unstable Patients
Patients Refusing Emergency Treatment
Transfers
Appropriate Transfers
Acceptance of Transfers
Transfer Certification
Patient Request for Transfer, Risks and Benefits
EMTALA 3: Documentation (Supplemental Module)
(Customizable)
Compliance Topics:
Documenting the MSE
Documentation for Patients Refusing Emergency Treatment
Transfer Certification
Documenting Patient Request for Transfer
Documenting Transfers
Transfer Summary Form
Transfer Summary Form: Common Pitfalls
Documenting On-Call List
Required Signage
Central Log
EMTALA 4: Applying EMTALA at Other Facilities & Off-Campus Departments (Supplemental Module)
(Customizable)
.
Compliance Topics:
Entities Affected by EMTALA
Provider-based Status and EMTALA
What is Considered a DED
What is Not Considered a DED
Hospital Property
Hospital Property: Examples
Off-Campus Departments
Ambulance Services
Non-Provider-Based Facilities
EMTALA 5: On-Call Coverage (Supplemental Module)
(Customizable)
Compliance Topics:
Physician Scope of Privileges
On-Call List
Physician On-Call Requirements
Additional On-Call Requirements
Consequences of On-Call Coverage
Use of Non-Physician Practitioners
CMS Interpretive Guidelines
Updating the On-Call Schedule
Sending Patients to the Physician’s Office
EMTALA 6: Investigations (Supplemental Module)
(Customizable)
Compliance Topics:
EMTALA Investigations
Sources of Allegations
Investigating Agency
Investigation: Record Review
Peer Review by CMS
Medical Review by CMS
Penalties and Enforcement
Fines and Other Penalties
Trends in Enforcement
Research Compliance for Non-Study Personnel
(Customizable)
Compliance Topics:
The Belmont Report
The Distinction Between Practice & Research
Basic Ethical Principles in Human Subjects Research
Regulatory Research
FDA Regulations
Regulations for Non-HHS Agencies
The “Common Rule”
Protections for Vulnerable Populations
Conflicts of Interest/Examples
Subject Selections
Subject Recruitment
Informed Consent Process
Research Involving Children – Assent & Permission
Assessment of Risks & Benefits
Research Billing
Understanding the Risks of Research
In-Depth HIPAA Compliance Courseware
Scenarios, Testing, Healthcare Compliance Examples
In-Depth HIPAA Compliance Courseware: Scenarios, Testing, Healthcare Compliance Examples
HIPAA 1: General Staff
(Customizable)
HIPAA Compliance Topics:
Privacy Rule
Reasonable & Permissible Uses & Disclosures
Protected Health Information (PHI)
Notice of Privacy Practices (NPP)
PHI – Use and Disclosure
PHI – Treatment, Payment & Operations (TPO)
PHI – Public Health Reporting
PHI – Opportunity to Agree or Object
Minimum Necessary Rule
Incidental Disclosures
Texting & Social Media
Security Rule
Security – Email & Internet Use Guidelines
Security – Facility
Security – Breach Notification
Patient’s Rights Under HIPAA
Reporting
HIPAA 2: Management & Physicians
(Customizable)
.
HIPAA Compliance Topics:
Notice of Privacy Practices (NPP)
Protected Health Information (PHI)
Texting & Social Medi
Admissions & Registration
Incidental Disclosures
Patient Care
Security
Breach Notification
Medical Records
Administration & Hospital Operations
Document Retention
HIPAA 3: Medical Records Personnel – Both Staff & Management
(Customizable)
HIPAA Compliance Topics:
Patient Rights
Protected Health Information (PHI)
Access to PHI
Texting & Social Media
Patient Access to PHI
Denial Access
PHI - Disclosures
PHI - Authorizations
PHI – Minimum Necessary Rule
Amendments
Amendment Denials
Accounting of Disclosures of PHI
Disclosures Required to be an Accounting
Disclosures NOT Required to be an Accounting
Business Associates
Verification of Identity & Authority
Security
Incidental Disclosures
Breach Notification
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