A Closer Look at our Compliance Training Courses

includes scenarios, case studies, healthcare compliance examples, and course-ware testing. 

 

Fraud & Abuse Level 1: General Staff                                                                                                       

 

This module will provide a basic understanding of the Fraud and Abuse laws – the laws that protect health care programs like Medicare and Medicaid from paying claims that are fraudulent or wasteful. The course will address your reporting obligations if you suspect a fraud and abuse violation.

 

Fraud and Abuse Compliance Topics:

Fraud Key Points

Abuse Key Points

Reporting Fraud & Abuse

Key Points: Documentation

Key Points: Record Retention

Key Points: False Claims Act

Key Points: Anti-Kickback Statute

Key Points: Stark Law

Key Points: Reporting

 

Recommended Audience:, Nurses/Patient Care Providers, Laboratory, Physician Office Staff, Skilled Nursing/Long Term Care, Home Care, Hospice, Physicians-Employed, Information Systems, Therapies, Board Members, Radiology, Pharmacy, ER Staff, Dialysis, Cardiac Services

 

 

Fraud & Abuse Level 2: Intermediate                                                                                                       

 

This course is divided into modules

                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

 

Upon completion of this course, you should be able to understand and describe: the importance of organizational values and ethics, the difference between fraud and abuse, the laws and regulations enacted to prevent fraud and abuse, a conflict of interest and how to manage it, your disclosures and reporting obligations, the state and federal enforcement agencies and initiatives, an effective compliance program, and your responsibilities as a member of management to the organization.

 

Section 1: Value and Ethics Compliance Topics:

Compliance responsibilities

 

​Section 2: Fraud and Abuse Compliance Topics:

Types of Fraud

Prevention of Fraud

Abuse

Prevention of Abuse

Key Points: Fraud & Abuse

False Claims Act (FCA)

The Affordable Care Act of 2010 (ACA or Healthcare Reform)

State False Claims Acts

Key Points: False Claims Acts

Anti-Kickback Statute

Anti-Kickback Statute: Safe Harbors

Anti-Kickback Statute: Penalties

Stark Law

Stark Law: Penalties

Section 3: Conflict of Interest Compliance Topics:

Potential 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

Module 6: Management Responsibilities Compliance Topics:

Management Responsibilities & Duties

 

Recommended Audience: Management

 

 

Fraud & Abuse Level 3: Advanced                                                                                                           

 

This course is divided into modules:

                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

 

Upon completion of this course, you should be able to understand and describe: the importance of organizational values and ethics, the difference between fraud and abuse, the laws and regulations enacted to prevent fraud and abuse, a conflict of interest and how to manage it, your disclosures and reporting obligations, the state and federal enforcement agencies and initiatives, areas of high risk for fraud and abuse, an effective compliance program.

 

Section 1: Value and Ethics Compliance Topics:

Compliance values and ethics

 

Section 2: Fraud and Abuse Compliance Topics:

Types of Fraud

Prevention of Fraud

Abuse

Prevention of Abuse

Key Points: Fraud & Abuse

False Claims Act (FCA)

The Affordable Care Act of 2010 (ACA or Healthcare Reform)

Could a False Claim Exists

Billing for Services Not Provided

Billing for Services Not Documented in the Medical Record

Unbundling

Upcoding

Falsifying Statements

Failure to Refund Over-payments within 60 Days

Duplicate Billing

Admissions

Billing the Wrong Units for a Particular Medication

State False Claims Acts

Qui tam Provisions

Anti-Kickback Statute

Anti-Kickback Statute: Safe Harbors

Anti-Kickback Statute: Penalties

Stark Law

Stark Law: Penalties

Section 3: Conflict of Interest Compliance Topics:

Potential 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

Your Role in Compliance

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

 

Recommended Audience: Coders, HIM, Coding Specialties, Billing/Financial Services, Admitting/Registration, Finance,

 

Patient Relationships and Compliance                                                                                                    

 

This course will identify the components of good patient service, list and describe three important steps to take when responding to a patient complaint, describe the four pieces of information you need when contacting your supervisor about a patient complaint, describe four key benefits that can result from tracking patient complaints, and identify the proper steps for handling a patient complaint that is outside the scope of your job responsibilities.

 

Compliance Topics:

Providing Good Service

Handling Patient Complaints

Increasing Awareness of Recurring Issues

Resolving a Complaint

Complaints and Associated Risks

 

Recommended Audience: All Staff

 

Admissions & Registration 1: Collecting Patient Demographics                                                           

This course will provide you with specific information on collecting patient information at the time of admission and/or registration. By the end of the course you will be able to list the key steps involved in the patient registration process, name and describe the three categories of information that make up a patient’s demographic information, describe important insurance information you should obtain when registering a patient, explain why routine waiver of patient co-payments, co-insurance and deductibles could be a compliance issue, and identify at least two forms that may need to be completed during the patient registration process. 

 

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

 

Recommended Audience: Coders, HIM, Billing/Patient Financial Services, Admitting, Registration, Laboratory, Skilled Nursing/Long Term Care, Home Care, Hospice, Finance, Physicians-Employed, Therapies, Radiology, Pharmacy, ER Staff, Dialysis, Cardiac Services

 

 

Admissions & Registration 2: ABNs and MSPs                                                                                         

 

This course discusses collecting additional patient information necessary for patient registration, while following the compliance requirements for your facility.

 

The course defines an Advance Beneficiary Notice (ABN) of Non-coverage, describes the minimum information that must be included on an ABN, identifies the types of services not covered by Medicare, explains when ABNs are not appropriate, identifies what the MSP questionnaire is and why it is used, and describes the patient and the facilities options if a patient refuses to sign an ABN.

 

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

 

Recommended Audience: Coders, HIM, Billing/Patient Financial Services, Admitting, Registration, Laboratory, Skilled Nursing/Long Term Care, Home Care, Hospice, Finance, Physicians-Employed, Therapies, Radiology, Pharmacy, ER Staff, Dialysis, Cardiac Services

 

 

Admissions & Registration 3: Observation Services, HIPAA and Other Compliance RisksTime:           

 

The course will define and provide an example of observation services, explain the difference between a regular and direct admission to observation, name and describe the three administrative simplification provisions included under HIPAA, list at least three situations that could result in a violation of patient confidentiality, explain why Medicare, Medicaid and third party payers are usually not considered the primary insurance for investigational and research procedures, define EMTALA and explains how this law can affect the registration process, explain why it is important to keep orders for patent services on file, and explain what a standing order is and what you can do if a standing order has expired.

 

Compliance Topics:

Observation Services                                        

Observation Services-Exclusions

Registering Observation Services                   

Changing an Inpatient to Observation Services

Observation Services- Cases                          

  Over 24 hours                                                   

Invalid Ordering/Referring Providers

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                          

Invalid Ordering/Referring Providers

Handling Standing Orders that have Expired

 

Recommended Audience: Coders, HIM, Billing/Patient Financial Services, Admitting, Registration, Laboratory, Skilled Nursing/Long Term Care, Home Care, Hospice, Finance, Physicians-Employed, Therapies, Radiology, Pharmacy, ER Staff, Dialysis, Cardiac Services

 

 

Allied Health Services 1: Medical Necessity                                                                                            

 

This course will define medically necessary services, list the four key factors that support medical necessity for Medicare services, identify and describe the similarities and differences between National Coverage Determinations and Local Coverage Determinations, identify two ways diagnostic information may be submitted by healthcare providers, and describe the four diagnosis coding guidelines that can help prevent false claims.

 

Compliance Topics:

Establishing Medical Necessity                                       

Medical Necessity

Medical Necessity Guidelines                                         

National Coverage Determination

National Coverage Determination Examples                              

Local Coverage Determinations

Local Coverage Determination Examples                    

National & Local Coverage Determinations

Diagnosis Coding Confirmation                                     

Diagnosis Coding

Requirements to Furnish Diagnostic Information

 

Recommended Audience: Management, Billing/Patient Financial Services, Admitting, Registration, Physician Office Staff, Physicians-Employed

 

 

Allied Health Services 2: Covered and Non-Covered Services                                                            

 

This course will define an Advance Beneficiary Notice of Non-Coverage (ABN), describe the minimum information that must be included on an ABN, identify the types of items and services that are not covered by Medicare, explain when ABNs are not appropriate, identify what the MSP questionnaire is and why it is used, and describe patient and facility options if a patient refuses to sign an ABN.

Compliance Topics:

Advance Beneficiary Notices                                           

Advance Beneficiary Notice Requirements

Non-covered Services                                                       

Screening Services

ABN Forms                                                                          

Completing the ABN 

Completed ABNs                                                               

Other ABN Forms

Services Never Covered by Medicare                           

Non-Covered 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

                               

Recommended Audience: Management, Billing/Patient Financial Services, Admitting, Registration, Physician Office Staff, Physicians-Employed

Allied Health Services 3: Processing Orders                                                                                           

Compliance is just as important to hospital reimbursement as coding and accounting. To obtain reimbursement for services, you will need to understand the regulatory requirements for processing different kinds of orders that may be received in your department. This course will identify an authorized provider, describe proper procedures and time frames for confirming verbal/telephone orders, describe the Medicare 3-Day (1-Day) Payment Window Policy and explain when outpatient services must be included in an inpatient stay based on the Rule, identify and describe the three main instances when charges may not accurately represent the services that were performed, describe the appropriate action to take when you receive an unclear order, and list the four key pieces of information you need to document when confirming an unclear order, and explain why orders/requests for tests must be kept on file.

Compliance Topics:

Processing Orders

Authorized Providers

Invalid Ordering/Referring Providers

Retention of Orders/Referrals

Verbal/Telephone Orders

Verbal/Telephone Orders-Timeframes

Three-day Outpatient Payment Window Rule

Services Ordered and Performed

Charge Capture Process

Unclear Orders

Unclear Orders-Documentation

Recommended Audience: Management, Billing/Patient Financial Services, Admitting, Registration, Physician Office Staff, Physicians-Employed

Allied Health Services 4: Billing Compliance                                                                                          

This course will describe the difference between routine supplies and separately billable supplies, identify and describe potential violations of the False Claims Act and Anti-kickback Statute, such as unbundling, billing for routine supplies, duplicate billing and inconsistent charges and discounts, list four key changes that may require review of your Charge Description Master, and list four outcomes that could result from improper reporting of HCPCS codes.

Compliance Topics:

Billing Compliance-Overview

Separately Billable Supplies

Separately Billable Supplies-Ambulatory Payment Classification

Unbundling of Multiple Procedures

Duplicate Orders

Duplicate Orders-OIG Investigations

Charge Master Description

Changes to the Charge Master Description

The Department’s Role in HCPCS Code Assignment

Modifiers

Modifier-Examples

Investigational and Research Use Only Procedures

Consistency of Charges

Consistency of Charges-Examples

Discount Policies

Recommended Audience: Management, Billing/Patient Financial Services, Admitting, Registration, Physician Office Staff, Physicians-Employed

Allied Health Services 5:  Cardiology                                                                                                         

This learning course will help you understand several basic concepts related to compliance and cardiac care. This course will define observation services and how they are reported, name two types of contrast materials used during certain radiology and imaging procedures and describe options for reporting these services, describe two specific problems that can lead to large differences in costs of cardiac catheterization services, describe proper billing procedures when submitting claims for electrophysiology services, define cardiac rehabilitation program services, and identify the two major criteria necessary when deciding if cardiac rehabilitation programs are reasonable and necessary.

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

Recommended Audience: Management, Billing/Patient Financial Services, Admitting, Registration, Physician Office Staff, Physicians-Employed

Allied Health Services 6:  Dialysis                                                                                                             

 

This learning course will help you understand several basic concepts related to compliance and dialysis services. This course will explain when a patient becomes eligible for Medicare ESRD benefits, identify when the ESRD Medical Evidence Report must be filed, identify QIP requirements for dialysis facilities, describe what a standing order is and how often it must be renewed for ESRD patients, explain what should happen if a patient is unavailable for all treatments during a month and describe the new bundled payment system for outpatient dialysis.

 

Compliance Topics:

Dialysis Services

ESRD Medicare Entitlement

Medicare Eligibility

ESRD Medical Evidence Report

ESRD Medical Evidence Report: Completion

ESRD Quality Initiatives Quality Reporting

ESRD Prospective Payment System (“PPS”)

Home Dialysis Payment Method

Home Dialysis Support Services

Partial Month Services

Epoetin Alfa and Darbepoetin Alfa

Renal Dialysis Services ESRD Drug Categories

ESRD Testing and the 50/50 Rule

Standing Orders

Items to List on Standing Orders

Handling Standing Orders that have Expired

 

Recommended Audience: Management, Billing/Patient Financial Services, Admitting, Registration, Physician Office Staff, Physicians-Employed

 

 

Allied Health Services 7:  Radiology                                                                                                        

 

This learning module will help you understand several basic concepts related to compliance and radiology. This module will define the types of contrast materials and proper charge reporting contrast, provide an example of interventional radiology services and necessary billing procedures, differentiate between a diagnostic mammography and a screen mammography, describe proper billing of radiology services related to skilled nursing facility (SNF) patients, list necessary requirements for radiology students to perform procedures, list different ways to bill charges for radiology services, and describe when it is appropriate for a facility to bill set-up and transportation fees for x-rays performed with portable equipment.

 

Compliance Topics:

Contrast Material

Charging for Contrast Materials

Interventional Radiology

Interventional Radiology: S & I

Mammography

Mammography: Frequency of Screening Exams

Mammography: Charging for Services

Identifying and Charging Mammography Services

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

Portable X-Ray Services: Separate Billing

Radiology Services: Regulatory Updates

Recommended Audience: Management, Billing/Patient Financial Services, Admitting, Registration, Physician Office Staff, Physicians-Employed

 

 

Allied Health Rehabilitative Therapies 8: Therapy Care                                                                         

 

This learning module will Provide you with general information about how the regulatory environment and documentation affects payment for therapy services. This module will identify the different payment methodologies for therapy services, list three steps CMS takes to promote accurate payments to providers, describe two documents provided by the OIG and how they can be used by therapy providers to improve compliance, describe the difference between the plan of care, certification/re-certification, progress reports and treatment notes, explain when therapy treatment can begin, explain delayed certification and when it is acceptable, define durable medical equipment, explain when reporting a re-evaluation would be appropriate, and identify tools that are available to provide objective, measurable patient function information.

 

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

Re-certification                                                                    

Durable Medical Equipment

DME & 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

ProgramsTreatment Notes

 

Recommended Audience: Management, Billing/Patient Financial Services, Admitting, Registration, Physician Office Staff, Physicians-Employed

 

 

Allied Health Rehabilitative Therapies 9:  Coding & Billing                                                                 

 

Proper coding and billing is one key compliance risk area identified by the Office of Inspector General (OIG) in the Compliance Program Guidance and annual Work Plans. This module will explain how NCCI edits are used to identify improper billing, describe the requirements for properly documenting and reporting a service based on time, describe the steps a therapist can take to verify charge accuracy, list two practices that can result in false claims, explain the requirements for properly reporting group therapy services, describe the difference between group therapy and providing individual care to multiple patients at the same time, define therapy caps and where they apply, explain the difference between general and direct supervision and how this applies to assistants, students and aides, and identify how services of assistants, students and aides are billed.

 

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, Assistants and Aides

Supervision and Billing

Certification of Foreign Born Therapists

Other Therapy Billing Issues

 

Recommended Audience: Management, Billing/Patient Financial Services, Admitting, Registration, Physician Office Staff, Physicians-Employed

HIM Coding Compliance 1: General Coding Issues                                                                             

 

This module will provide information regarding steps to take to promote proper coding in both the inpatient and outpatient setting. This module will define medical necessity, explain the difference between a statutorily excluded service and a medically unnecessary service, describe how medical necessity is identified, define up-coding, list the benefits of a physician query process, and list what a query form should and should not contain.

 

Compliance Topics:

Medical Necessity                                              

Steps to Determine Medical Necessity

Statutorily Excluded Services                          

Medically Unnecessary Services

Screening Services                                            

Medical Necessity Software

Up-coding                                                            

Physician Query Process

Query Format and Response

 

Recommended Audience: Coders, HIM, Coding Specialties

 

 

HIM Coding Compliance 2: Inpatient/Outpatient Coding                                                                        

 

This module will provide information regarding steps to take to promote proper coding in both the inpatient and outpatient setting. The module will describe the difference between DRGs and MS-DRGs, list the three criteria established under the Uniform Hospital Discharge Data Set (UHDDS) for reporting inpatient services, describe why it is important to list discharge/transfer status codes on a claim and what can happen if the codes are improperly reported, identify the differences in code set(s) used to report inpatient and outpatient services, list two differences in reporting diagnoses between inpatient and outpatient services, and list four different ways HIM departments can improve outpatient documentation.

 

Compliance Topics:

Inpatient Coding

Inpatient Diagnoses Coding

Consequences of Improper Coding

Discharge/Transfer Status Codes

Discharge/Transfer MS-DRGs

Identifying Proper Discharge/Transfer Status Codes

Compliance and Discharge/Transfer Codes

Past OIG Findings Regarding Improper Discharges/Transfers

Problematic DRGs

Outpatient Procedure Coding & Examples

Outpatient Diagnosis Coding

Outpatient Diagnosis Coding-Applying ICD-9-CM Rules

Outpatient Diagnostic Guidelines

Outpatient Documentation Guidelines

 

Recommended Audience: Coders, HIM, Coding Specialties

 

 

HIM Coding Compliance 3: Coder Education and Ethics                                                                         

 

This module will provide information regarding coder education and ethics. This module will explain the OIGs position on coder education, identify at least three additional topics outside of coding that coder training should address, list at least two OIG recommendations related to coder education and training, name two organizations that offer coding credentials, explain what can happen if a certified coder does not maintain the required number of continuing education hours, list at least four key points from AHIMA’s ethical standards for coding, identify the three coding references that must be updated at least annually, and describe how coding review/audits can be a part of the coder education process.

 

Compliance Topics:

OIG Requirements                                                             

Education Methods

Coder Training                                                                    

Coding Credentials

AHIMA                                                                                  

AAPC

Ethical Standards                & Examples                                        

Government Resources

Coding Resources                                                             

Coder Feedback

AHIMA’s Standards for Ethical Coding

 

Recommended Audience: Coders, HIM, Coding Specialties

 

HIM Compliance Management 1: An Effective Compliance Program                                                       

           

This module will provide you with general information about the components of an effective compliance program including policies, procedures, and ongoing reviews necessary to promote complete, and accurate coding. This module will list and describe the seven elements of an effective compliance program, describe the responsibilities of the Compliance Officer in the facility, provide two examples of anonymous reporting mechanisms, name at least three topics that should be covered in department-level compliance training for HIM staff, and define what is meant by an individual who is “excluded from participation.”

 

Compliance Topics:

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

 

Recommended Audience: Coders, HIM, Coding Specialties

 

 

HIM Compliance Management 2: HIM Compliance Policies                                                                 

 

This module will provide you with general information about HIM compliance policies and procedures. This module will name three minimum documentation requirements recommended by the OIG Compliance Program Guidance for Hospitals, define the Uniform Hospital Discharge Data Set (UHDDS), define the charge description master, name two sources that provide diagnostic coding guidance, list the four cooperating parties that help develop the official ICD-9-CM coding guidelines, and describe an inappropriate financial incentive that might be offered to coders or contractors.

 

Compliance Topics:

Documentation: Policies & Procedures                         

Documentation: Minimum Requirements

Documentation: Code Assignment                                

Quality Improvement Organizations

Proper Selection and Sequencing of Diagnosis          

Official ICD-9-CM/ICD-10-CM Coding Guidelines

Coding Guidelines                                                             

ICD-10-CM Coding

Coding Resources                                                             

Professional Organizational Agencies

Chargemaster: Coordination                                           

Chargemaster: Updates

Chargemaster Updates: Coordination                           

Coder Incentives

Appropriate Coding Incentives                                        

Service Contracts

Service Contracts: Contractor Incentives

 

Recommended Audience: Coders, HIM, Coding Specialties

 

 

HIM Compliance Management 3: Coding Quality Reviews                                                                    

 

This module will provide you with general information about HIM auditing and monitoring activities. This module will explain the difference between internal and external reviews, describing the benefits of each method, describe the key differences between pre-billing quality reviews and retrospective reviews, explain the difference between re-bills and refunds to Medicare, define random sampling and list two methods of random sampling, explain the main benefit of focused sampling, and define the Program for Evaluating Payment Patterns Electronic Reporting (PEPPER).

 

Compliance Topics:

Coding Quality Reviews                                                    

Internal Reviews

External Reviews                                                                

Pre-billing Reviews

Rebilling Policies

Tracking Rebilled Claims                                                 

Random vs. Focused Samples

Random Selection of Records                                         

Focused Selection of Records

Audit Trends                                                                        

Audit Trends: Benefits

Comparative Statistics                                                      

Analyzing Trends: Case Mix

OIG Work Plan                                                                    

PEPPER

PEPPER Uses                                                                     

PEPPER Data and Outliers

PEPPER Focused Audits                                                  

Reporting Quality Review Activities

Coding Error Patterns                                                        

National Correct Coding Initiative

CCI: Examples

 

Recommended Audience: Coders, HIM, Coding Specialties

HIM General Compliance 1: Regulatory Environment                                                                             

 

This module will give you an overview of the regulatory environment to Health Information Management services. This module will list five requirements of the Conditions of Participation for Hospitals, identify five organizations or agencies that offer facility accreditation, list three areas where HIM can affect accreditation surveys, name four items addressed by HIPAA, and describe the documentation requirements for teaching physicians.

 

Compliance Topics:

Regulatory Environment

Federal Agencies

Conditions of Participation               

Conditions of Participation Updates

Quality Assessment Performance Improvement

State Agencies

Voluntary Accreditation Programs

The Joint Commission Accreditation Manual for Hospitals

HIM and Accreditation

HIPAA

HIPAA and Confidentiality

Balanced Budget Act of 1997

Recovery Audit Program                                   

Physicians at Teaching Hospitals (PATH) Audits

Teaching Physician Documentation

Electronic Signature Requirements

 

Recommended Audience: Coders, HIM, Specialties

 

 

HIM General Compliance 2: HIM Practice Implications                                                                          

 

This module will provide an example of how requirements may differ between CMS, the Joint Commission and your facility policies and procedures and identify which requirement you should follow, list three Joint Commission requirements that are challenging for HIM professionals, describe delinquent record compliance criteria, explain what the National Patient Safety Goals are and when they are updated, describe when authorization is required to release patient information, explain the difference between confidential and non-confidential information, and describe the process to correct an error in a paper based and computer based patient record.

 

Compliance Topics:

Practice Implications                                                         

Differences in Requirements

Joint Commission Challenging Areas                           

Ambulatory Summary Lists

Medical Record Review                                                    

Delinquent Records

Delinquent Records Levels of Compliance                  

Joint Commission Updates

Unannounced Inspections                                               

Patient Safety Goals

Tracer Methodology                                                           

Health Information

Confidentiality                                                                     

Release of Information

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

 

Recommended Audience: Coders, HIM, Specialties

 

 

Nursing Documentation 1: Medical Necessity, Forms, and ABNs                                                        

 

This course will provide you with general knowledge about the rules and regulations affecting nursing providers today. The course will identify the various forms used in healthcare settings, describe two situations when an Advance Beneficiary Notice would be appropriate, explain why it is improper to provide an ABN to all patients for every service procedure that is performed and define medical necessity.

 

Compliance Topics:

Medical Necessity                                              

Medical Necessity-Requirements

Guidelines                                                           

Forms, Consents & Directives

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                 

 

Recommended Audience: Nurses/Patient Care Services, Skilled Nursing/Long Term Care, Home Care, Discharge Planning, Hospice, Therapies

 

 

Nursing Documentation 2: Documentation & Orders                                                                          

This course will list four uses of the medical record, describe how to make appropriate late entries and corrections to the medical record, describe the consequences of inappropriate or inaccurate documentation, and identify what you should do if a valid order is not documented in the medical record.

 

Compliance Topics:

General Principles of Documentation

Primary Use of the Medical Record

Abbreviations

Authentication of Entries

Late Entries

Late Entries-Paper and Electronic Medical Records

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

 

Recommended Audience: Nurses/Patient Care Services, Skilled Nursing/Long Term Care, Home Care, Discharge Planning, Hospice, Therapies

 

 

Nursing Documentation 3: Rules, Regulations, Laws and Statutes                                                      

 

This module will provide you with general information about the regulatory environment affecting healthcare providers today. This module will describe the Health Insurance Portability and Accountability Act (HIPAA) and provide examples of potential violations, identify why confidentiality is important and list three areas where specific confidentiality requirements apply, explain the Stark Laws and Anti-kickback Statute and describe potential violations, describe how releasing patient information if affected by specific conditions including treatment for alcohol or drug dependency, HIV/AIDs and court orders, explain what you must do when providing a referral for post-acute care to patients, and define EMTALA and how it affects nursing services.

 

Compliance Topics:

Principles of Medical Record Documentation-Overview

HIPAA and Confidentiality

Protected Health Information (PHI)

Medical Records

Authorizations

Confidentiality & Release of Information

Review of Stark Laws & Anti-Kickback Statute

Stark Laws Overview

Exceptions to the Stark Laws

Anti-Kickback Statute

Vendor Gifts and the Anti-Kickback Statute

Patient Gifts and the Anti-Kickback Statute

Related Entities and Freedom of Choice

EMTALA Overview

EMTALA Registration

 

Recommended Audience: Nurses/Patient Care Services, Skilled Nursing/Long Term Care, Home Care, Discharge Planning, Hospice, Therapies

 

Nursing Documentation 4: Other Compliance Topics                                                                            

 

This module will identify the importance of the ongoing assessment, explain the requirements for observation services, explain what the Three-Day Rule is and how it affects billing for inpatient admissions, describe how to handle unused medication, and identify some of the services that can be performed by non-nursing personnel.

 

Compliance Topics:

Ongoing Assessment-Medical Necessity

Ongoing Assessment-Timely Communication

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

Why is the Admission Status Such an 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

 

Recommended Audience: Nurses/Patient Care Services, Skilled Nursing/Long Term Care, Home Care, Discharge Planning, Hospice, Therapies

 

 

Skilled Nursing 1: Three-Day Prior Hospitalization                                                                                 

 

The risks of non-compliance with existing requirements will be identified throughout the courses with specific rules, regulations and requirements cited.

 

Some of the laws, rules and guidelines pertaining to skilled nursing and covered in these courses include: Medicare Part A and Part B, Balanced Budget Act of 1997-Prospective Payment System, OIG Compliance Program Guidance for Nursing Facilities, the Omnibus Reconciliation Act of 1987, Anti-kickback Statute and the Stark Physician Self-Referral Law, the Patient Protection and Affordable Care Act (PPACA) and the American Taxpayer Act of 2012.

 

Compliance Topics:

Review of Regulatory Requirements

Verification of Compliance

Consequences of Non-Compliance

 

Recommended Audience: Skilled Nursing/Long Term Care, Discharge Planning, Hospice, Physicians-Employed

 

 

Skilled Nursing 2: Medical Necessity & Utilization Review                                                                     

Compliance Topics:

What is Necessary for Coverage in a SNF

Skilled Nursing Services

Skilled Rehabilitation Services

Verification of Benefits/MSP/Assignment of Benefits

Physician Certification/Re-certification

Recommended Audience: Skilled Nursing/Long Term Care, Discharge Planning, Hospice, Physicians-Employed

Skilled Nursing 3: MDS, Billing and Reimbursement                                                                               

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

Recommended Audience: Skilled Nursing/Long Term Care, Discharge Planning, Hospice, Physicians-Employed

 

 

Skilled Nursing 4: Patient Care Issues                                                                                                      

 

Compliance Topics:

Quality of Care-OIG Guidelines

Residents Rights

Ongoing Assessment

 

Recommended Audience: Skilled Nursing/Long Term Care, Discharge Planning, Hospice, Physicians-Employed

 

 

Skilled Nursing 5: Other Compliance Issues                                                                                            

 

Compliance Topics:

Documentation

Referral Relationships

Hospice & Skilled Nursing

Medicare Part D

 

Recommended Audience: Skilled Nursing/Long Term Care, Discharge Planning, Hospice, Physicians-Employed

 

 

Patient Financial Services 1: General Compliance                                                                                  

 

This course will provide you with general information about how the regulatory environment affects a facility’s ability to receive payment for services. This course will define medically necessary services, identify the types of services that are not covered by Medicare, describe the purpose of an Advance Beneficiary Notice of Non-coverage (ABN), list the five pieces of information, at minimum, included on an ABN, provide two examples when the use of an ABN is not appropriate, and describe different patient and facility options if a patient refuses to sign an ABN.

 

Compliance Topics:

Medical Necessity                                                              

Non-Covered Services

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 with Medical Necessity Guidelines

Advanced Beneficiary Notices and PFS

Advanced Beneficiary Notice Requirements

Other Financial Responsibility Forms

 

Recommended Audience: Billing/Patient Financial Services

 

 

Patient Financial Services 2: Claims Processing                                                                                     

 

This module will provide you with information about how the regulatory environment affects a facility’s ability to process claims and receive payment for services. This module will explain why a Medicare Secondary Payer questionnaire is needed, describe the Three-day Outpatient Payment Window Rule, define the Charge Description Master and describe at least two important items on your facility’s CDM that should be reviewed at least annually, define observation services and describe the conditions necessary to receive reimbursement from Medicare, and name at least two types of services that are NOT included in the composite rate payment calculation used for End Stage Renal Disease services.

 

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

 

Recommended Audience: Billing/Patient Financial Services

 

 

Patient Financial Services 3: Claims Submission                                                                                 

 

To receive reimbursement from Medicare, the facility must submit a claim with the appropriate information. Prior to submission of the claim, it is necessary to review and edit the claim to verify the information listed is complete and accurate.

 

This module identifies at least three different systems that can affect claims, list two reasons why claims are held, explains how late charges are submitted for compliant billing, names at least three major categories of information found on the UB-04 claim form, defines the National Provider identification number and explain when it is used, describes the two types of duplicate charges and gives an example of each, explains what a “Return-to-Provider” report is and why it should be reviewed, and describes the difference between “re-billing” and “re-submission” of claims.

 

                                                                                                                                             

Compliance Topics:

Systems Integrity

Implementation on the NPI

Claims Editing

Holding Claims                   

Late Charges                                                      

Claims Editing: UB-04 Form                            

Claims Editing: Policies & Procedures

Duplicate Charges

Duplicate Claims

Duplicate Orders- OIG Investigation

Return to Provider Reports

Re-billing/Re-submission

Electronic Claims

Electronic Billing Integrity & Examples

 

Recommended Audience: Billing/Patient Financial Services

 

 

Patient Financial Services 4: Payments & Refunds                                                                                

 

After the claim has been submitted to the payer, the next step in the process relates to payment and denials for those services.

 

This module describes the difference between contractual adjustments, write-offs

and credit balances and gives examples of each, explains why it is important to have a Denials Management program in place and communicate this information with other departments, explains the process of reporting credit balances to Medicare, names at least three criteria that must be met before assigning non-collectible accounts to bad debt, describes what APCs are and list at least three items that must be present on the claim to determine the APC for services provided to the patient, and describes the cost report and explains the connection between accurate patient claims and the cost report.

                                                                                                                                             

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

 

Recommended Audience: Billing/Patient Financial Services

 

 

Laboratory Administration 1: CLIA Certification                                                                                         

 

This course will provide you with an overview of CLIA certificates, what they are, and the requirements to maintain certification. This course will identify and describe the different types of laboratory tests, list three exceptions where a separate CLIA certificate is not required, list the types of CLIA certificates and describe each, identify three of the six approved accrediting agencies, list five changes in the laboratory that require notification to CMS, explain what CLIA exempt means, identify the successful completion requirements for proficiency testing, describe three criteria that must be followed when performing proficiency testing, identify the penalty for sending proficiency testing specimens to another laboratory, and identify how often laboratories are inspected, including laboratories that qualify for the Alternate Quality Assessment Survey (AQAS).

 

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                  

Exceptions

 

Recommended Audience: Laboratory, Physicians-Employed

 

 

Laboratory Administration 2: Laboratory Compliance Issues                                                                

 

In the laboratory, there are many different tasks that must be performed to promote efficient operations. Many of these tasks can also affect compliance. This module will describe at least three things you can do when designing a requisition to meet the OIG’s recommendations, explain three methods you can use to educate physicians on how to properly order laboratory tests, explain why it is important to provide annual notices to physicians, list at least four items that should be included in the annual notice, explain two methods the laboratory can use to monitor test utilization, identify the law that may be violated if physicians use equipment and supplies provided by the laboratory for their own use.

 

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

 

Recommended Audience: Laboratory, Physicians-Employed

 

 

Laboratory Administration 3: General Compliance Issues                                                                       

 

This module will describe the Stark Law and how it can affect billing for laboratory tests, explain how the laboratory’s record retention policies should be established in relation to regulatory guidelines as well as the facility’s global policy, list at least five specific documents the laboratory should retain for ordered tests and services, describe when a direct treatment relationship may exist in the laboratory, define what an outreach program is and list four areas that need to be addressed when setting up an outreach program, explain why it is important for laboratories to review denial reports, and list at least three different laws that are often applied during laboratory investigations.

 

Compliance Topics:

Stark Law & Exceptions                                                    

Record Retention

Record Retention and Compliance                                

Negotiated Rulemaking Standards

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 and Appeals

Applicable Laws

 

Recommended Audience: Laboratory, Physicians-Employed

 

 

Laboratory Coding & Pricing 1: Coding, Pricing and the CDM                                                                

 

This module will provide an overview of how HCPCS codes and modifiers are linked to tests in the Charge Description Master (CDM). This module will define HCPCS codes and modifiers, identify the criteria used to assign HCPCS codes for laboratory tests and services, explain the hierarchy for HCPCS code assignment, explain modifier -59 and -91 and provide an example of when each would be used, list three criteria that should be addressed when pricing laboratory services, identify two state regulations that could affect pricing for laboratory services, describe what the Charge Description Master (CDM) is and why it needs to be updated, and list at least three changes in the laboratory that could affect the CDM.

 

Compliance Topics:

HCPCS Codes                                                                    

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

                                   

Recommended Audience: Laboratory, Physicians-Employed

 

 

Laboratory Coding & Pricing 2: Special Coding Situations                                                                      

 

In most cases, coding and pricing of laboratory tests can be fairly straightforward as long as specific steps are taken to verify the codes selected are appropriate. There are some situations where the right choice is not as clear. This module will explain how Organ and Disease Oriented panels should be billed, explain the Office of Inspector General’s position on offering custom panels and profiles, describe steps laboratories should take if they choose to offer custom panels and profiles, explain any pricing concerns related to panels and profiles, define miscellaneous tests and the information needed to properly bill and report these services, explain the difference between Research Use Only (RUO) tests and testing performed for clinical trials, list billing considerations for RUO tests and clinical trials.

 

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

 

Recommended Audience: Laboratory, Physicians-Employed

 

Processing Laboratory Orders 1: Registration & Receipt of Orders                                                     

 

The rules and regulations for receiving and registering lab orders can be complex. To get paid for services, laboratories must obtain specific information. This module will identify patient information necessary for billing, list various forms used for registering patients and describe their importance, provide at least two examples when Medicare may be the secondary payer for a Medicare beneficiary, identify the correct date of service for laboratory tests, explain why orders/requests for tests must be kept on file, and describe the importance of the National Provider Identification number.

 

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

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

 

Recommended Audience: Laboratory, Physicians-Employed

 

 

Processing Laboratory Orders 2: Types of Laboratory Test Orders                                                       

 

The purpose of this module is to help you learn what you can do to promote compliance when handling different types of orders. This module will list the five hints that can help you identify that you may be working with an unclear order, list the four key pieces of information you need to document when confirming an unclear order, describe what a standing order is and what elements should be present on the order, explain how you can handle a standing order that has expired, identify the timeframe allowed for requesting confirmation of a verbal order, and describe two ways duplicate billing may occur.

 

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 and the OIG

Recommended Audience: Laboratory, Physicians-Employed

 

 

Processing Laboratory Orders 3: Processing Orders                                                                            

 

To avoid any compliance violations, laboratories should have procedures in place that promote laboratory compliance.

 

The course will define unbundling and describe what you can do to identify and prevent unbundling, define the Three-day Outpatient Payment Window Rule and provide examples of when lab services fall under this rule, describe how to report multiple specimens collected from a patient during the same encounter, provide examples of when a specimen collection fee may and may not be charged, explain the differences between reflex testing and confirmatory testing, define handling charges and STAT tests and provide an example of each, explain why handling charges and STAT fees cannot be charged to Medicare, and identify tests that are based on calculations and explain the billing rules that apply.

 

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 Test Reports & Handling Charges

Billing for Calculations & QC Tests

 

Recommended Audience: Laboratory, Physicians-Employed

 

Laboratory General Compliance 1: Medical Necessity                                                                          

 

This module will define medical necessity, identify four key criteria that must be met for Medicare to pay for tests, explain what National and Local Coverage Determinations are and what the differences are between the two, describe the difference between covered and non-covered services and give examples of each, identify when an ordering provider must submit a diagnosis to the laboratory, explain when the Advance Beneficiary Notice of Non-Coverage (ABN) should be obtained, describe the rules for obtaining ABNs for frequency based tests and standing orders, and explain what to do if a patient refuses to sign the ABN but demands the test be performed anyway.

 

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

ABN Requirements                                            

When an ABN should be Obtained

ABN of Non-Coverage                                      

Completing the ABN

Modifying ABNs

Obtaining ABN’s in the Emergency Department

Obtaining ABN’s After Receipt of the Specimen

Patient Options

Patient Options-Choices

Patient Options-Exceptions

 

Recommended Audience: Laboratory, Physicians-Employed

 

 

Laboratory General Compliance 2: Other Compliance Topics                                                                 

 

This module will provide you with information about specific regulatory topics affecting laboratories today. The module will describe the Direct Billing Requirement and identify three exceptions to this requirement, explain how the Direct Billing Requirement applies to hospital laboratories, list at least three laboratory discount policies that should be in place and why they are important, describe composite rate tests and identify who should be billed for laboratory tests paid under the composite rate, , describe two scenarios for tests provided to patients in skilled nursing facilities and who should be billed for those tests, define Point of Care testing and list at least three rules for proper reporting of POC testing.

 

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   

ESRD Testing

Testing for SNF Patients                                   

Who to Bill for Tests Performed

Establishing Prices for SNF Services                             

The OIG, Laboratories & SNF Testing

Point of Care Testing                                         

Charging for POC Testing

 

Recommended Audience: Laboratory, Physicians-Employed

 

 

Home Medical Equipment 1: Criteria                                                                                                      

 

This module will help you understand Medicare’s eligibility criteria for home health equipment.

Compliance Topics:

Definition of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

Reasonable and Necessary

Medical Necessity

Oxygen

Beds & Wheelchairs

Enterals & Parenterals

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

 

 

Home Medical Equipment 2: Documentation, Billing & Other Compliance Risks                               

 

This course is a continuation of Home Medical Equipment 1.

 

Compliance Topics:

Physician Orders                                

Delivery

Refills

Medical Necessity                              

Repairs & Maintenance

Equipment Replacement                  

Capped Rentals

Pre-billing Audit                                  

Rental of Space

Co-pays, Deductibles & Refunds    

Sales & Marketing Practices

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

 

 

Home Care 1: Regulatory Compliance                                                                                                       

This module will provide you with general information about how the regulatory environment affects a Home care provider’s ability to manage the risk of non-compliance and to receive payment for services.

 

This course will describe your role and how it affects compliance, list the three types of Medicare Administrative Contractors (MACs) and describe the functions they perform, describe the Medicare Conditions of Participation (COPs), describe the difference between certification, licensure and accreditation, define HIPAA and list the three main areas of the administrative simplification provision, explain what the Medicare Claims Processing Manual is and why it is important, and describe the four parts of the Medicare program and the types of services they cover. 

 

Compliance Topics:

Compliance Roles

  * Administrator

  * Clinical Manager

  * Field RN/Therapist/Case Manager

  * Home Health Aide

  * Performance 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

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

Home Care 2: Billing Compliance                                                                                                               

 

This module will provide you with general information about how the regulatory environment affects a Home Care provider’s billing practices.

 

This course will describe the basic requirements for the Home Care admission process, explain Medicare Secondary Payer requirements, list three forms commonly completed during the patient admission process, describe the Advance Beneficiary Notice (ABN) and when it is required, explain the Medicare appeals process for denied claims, and define the Anti-kickback Statute and Stark Laws and give examples of each.

 

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

Home Health  Change of Care Notice and NOMC: Q10 Review

Patient Options

Processing Additional Development 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 Laws

Examples of the Stark Laws

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

Home Care 3: Documentation Guidelines                                                                                                

                                       

This module will provide you with general information about how the regulatory environment affects a Home Care provider’s documentation practices.

 

This course will name at least three regulatory standards that govern the content of medical records, list at least four key documentation requirements for medical records, define medical necessity, explain how to select the appropriate timeline for obtaining written confirmation of a verbal order, define who is considered an authorized provider and give two examples, and list the minimum information that should be documented when contacting an ordering provider to clarify an order.

 

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

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

 

 

Home Health 1: Eligibility for Medicare Home Health Services                                                              

 

This course will provide you with general information about how the regulatory environment affects a home health agency’s ability to manage the risk of non-compliance and receive payment for services.

 

This course will explain the Medicare definition of homebound and provide an example of a homebound patient, name at least three factors necessary for a patient to be considered homebound, identify home health personnel who are authorized to perform skilled home health services, define intermittent or part-time services, explain the components necessary to initiate home care services for a patient, and describe situations where home health services would meet reasonable and necessary criteria.

 

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

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

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

 

 

Home Health 2: Home Health Documentation                                                                                          

 

This course will list two (2) different uses for documentation kept in a patient’s Plan of Care, define the Outcome and Assessment Information Set (OASIS), identify at least two (2) times during a patient’s care when the OASIS must be completed, name three (3) patient groups for whom the OASIS is not required, describe the components of a clinical note, and list some key elements that make documentation effective.

 

Compliance Topics:

Plan of Care

Plan of Care Documentation

OASIS

OASIS Tool

OASIS: Pitfalls

Completing the OASIS

Completing the OASIS: Exceptions

OASIS Submission Requirements

Clinical Notes

Clinical Notes: Effective Documentation

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

 

 

Home Health 3: Billing                                                                                                                                 

 

This course will identify the two split payments that accompany each episode of home health services, list the types of services that must be included on the home health claim, list the types of services that may be billed separately from other home health services, name two types of codes listed on a home health claim, explain the differences between information included in the end of episode claim, and define rebilling and resubmission.

 

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

Home Health Accounts Receivable

Re-billing/Re-submission

Transfers

Partial Episode Payments

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

 

 

Hospice 1: Eligibility Criteria for Hospice Services                                                                                

 

This course will investigate the eligibility criteria for Medicare hospice services. For a patient to receive care and qualify for reimbursement under his/her Medicare hospice benefit, the care must meet the requirements listed in the Medicare Benefit Policy Manual. The requirements include the following criteria:

  • The patient must be certified as

  • The hospice services must be reasonable and necessary for the palliation and management of the terminal illness as well as related conditions. The services must also be consistent with the plan of care.

  • The patient must have an that meets the hospice certification and election requirements.

  • The care must be divided into benefit periods.

  • The patient must be under an that is periodically reviewed by the attending physician, medical director, and interdisciplinary group of the hospice program. This plan of care must be established before hospice is provided.

 

Compliance Topics:

Definition of Hospice Care

Terminal Status and Certification

Specific Requirements Regarding Certifications

Determining Terminality

Benefit Periods

Hospice Election and Revocation

Hospice Evaluation and Counseling Services

Hospice Revocation/Discharge

Covered Diagnosis & LCDs

Interdisciplinary Group

Levels of Care (4)

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

 

 

Hospice 2: Documentation                                                                                                                       

 

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:

  • Plan of Care

  • Clinical Notes

 

Compliance Topics:

The Plan of Care

Clinical Notes

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

 

Hospice 3: Billing                                                                                                                                       

 

This course discusses the rules and guidelines for billing hospice services. Everyone in the hospice agency has a responsibility to make the billing process compliant with these rules, regulations and guidelines.

 

Compliance Topics:

Levels of Care and the Daily (Per-Diem) Rate

Per-Diem Rate Services

Availability of Services

Transfers

Hospice Pre-Billing Audits

Hospice Accounts Receivables

Hospice Claims Submissions

Hospice Denied Claims/Rebilling

Hospice Payments & Collections

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

 

 

Hospice 4: Other Compliance Risks                                                                                                       

 

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

Hospice Services Provided in Assisted Living Facilities

Volunteers

Underutilization

 

Recommended Audience: Billing/Patient Financial Services, Home Care, Discharge Planning, Hospice

 

 

Physician Coding 1: Evaluation & Management Services                                                                      

 

The primary focus of this course will be to provide physicians with information on how documentation in the patient chart is used to determine the appropriate Evaluation and Management (E&M) codes for the services they provide, and correspondingly, the payment that is received.

 

The purposes of this course are:

  • To foster and maintain a culture on integrity

  • To develop individual and team character and virtue in the workplace

  • To foster compliance with Applicable federal and state laws and regulations

  • To make sure facility policies and procedures are followed

 

The AMA established levels for the various categories of Evaluation and Management (E&M) services in the Current Procedural Terminology (CPT®) Manual. To clarify what would be required to support the levels of E&M services, the Centers for Medicare and Medicaid Services (CMS) has developed documentation guidelines to help providers determine which category and level of service to use for each patient encounter.

 

This course is intended to provide a thorough explanation of the CMS Documentation Guidelines (DGs) and provide the information necessary for you to evaluate your documentation and determine which E&M level is appropriate for every patient encounter

 

Compliance Topics:

E&M Key Components

E&M Key Components-New versus Established Patient

Patient History

Patient History-Chief Compliant

History of Present Illness

History of Present Illness (HPI) Elements

Review of Systems (ROS)

Review of Systems-Examples

Past Medical, Family, and/or Social History

Determining the Level of History

Examination Background–1985 Guidelines

Examination Background–1997 Guidelines

Examination-Documentation

Types of Examinations

Limited vs. Extended Examination Examples–1995 Guidelines

Examination Documentation

Examination Examples

Determining the Level of Examination

Medical Decision Making

Diagnoses or Management Options

Amount or Complexity of Data

Risk of Complications and/or Morbidity or Mortality

Table of Risks

Established Patient Guidelines

Risk of Complications

Contributory Components

Medical Decision Making-An Example

Medical Decision Making-Putting it Together

Nature of Presenting Problem

Counseling & Coordination of Care

Contributory Components-Time

E&M Code Selection

Score Sheets

Determining the Overall E&M Level of Service-New Patient

Determining the Overall E&M Level of Service-Established Patient

 

Recommended Audience: Physician Office Staff, Physicians-Employed

 

 

Physician Coding 2: Special Circumstances                                                                                             

 

This course addresses additional types of Evaluation and Management (E&M) services as well as other coding and documentation requirements you must follow. This includes:

  • Consultations

  • Unbundling/Comprehensive Codes

  • Teaching Physician Requirements

  • Modifiers

 

Compliance Topics:

Consultations Updated Requirements-Outpatient Services

Consultations-Updated Requirements-Inpatient Services

Other Payer Requirements for Consultations

Unbundling/Comprehensive Codes

Teaching Physician-Requirements

Teaching Physician-Documentation Guidelines

Teaching Physician-Documentation Examples

Teaching Physician-E&M Requirements

Teaching Physician-Specific Procedure Requirements

Modifiers

 

Recommended Audience: Physician Office Staff, Physicians-Employed

 

 

Physician Documentation 1: Rules & Guidelines                                                                                    

 

The primary focus of this course will be on proper documentation of services provided by the physician as well as diagnosis coding and billing of services to third party payers, including Medicare and Medicaid, in order to meet existing compliance requirements.

 

This course will identify the compliance risks facing physicians in the current regulatory environment, provide an understanding of the importance of complete and accurate clinical documentation, provide an understanding of the association between clinical documentation and the billing process,   identify the services that will or will not be paid by Medicare and Medicaid, provide an understanding of the components of a compliance program and how you could implement a compliance program in your practice, and provide an understanding of the practices that should be put in place in a physician’s practice to improve compliance with billing and coding laws and regulations.

 

Compliance Topics:

OIG Annual Work Plans                                    

Recovery Audit Contractors (RACs)                

Place of Service Rules                                      

Documentation

Documentation-Signatures                                              

Documentation-Medical Records

Documentation-Abbreviations                         

Diagnosis Coding

NCDs & LCDs                                                     

ABNs

“Incident To” Guidelines                                    

Non-Physician Practitioners

Split or Shared Visits                                         

Completion of Discharge Summaries

Joint Commission Requirements                   

Three-Day Outpatient Window Rule

Observation Status/Examples                         

Observation Status Guidelines

Physician Compliance Programs                   

2-Midnight Rule

Seven Compliance Standards                        

Four Risk Areas

Fourteen “OIG Highlights”

 

Recommended Audience: Physician Office Staff, Physicians-Employed

 

 

Physician Documentation 2: Anesthesia Specialty Guidelines                                                           

 

This course contains additional information on compliance rules and regulations specific to Anesthesia Specialties.

 

Compliance Topics:

Time/Unbundling                               

Medical Direction

Modifiers                                                              

Pulse Oximetry

Ventilation Management                                  

Pre-Anesthesia Visit

E&M Codes/Consultations

                               

Recommended Audience: Physician Office Staff, Physicians-Employed

 

 

Physician Documentation 3: Obstetrics & Gynecology Specialty Guidelines                                      

 

This course contains additional information on compliance rules and regulations specific to Obstetrics & Gynecology Specialties.

 

Compliance Topics:

Preventive Medicine Services                         

Modifier Abuse                                                   

Global Billing/Unbundling                                

Co-Surgery

Assistant at Surgery                                           

Certified Nurse Midwife (CNM)                                       

CNM Modifiers                                                    

Physician E&M Codes

PATH

 

Recommended Audience: Physician Office Staff, Physicians-Employed

 

 

Physician Documentation 4: Critical Care Specialty Guidelines                                                          

 

This course contains additional information on compliance rules and regulations specific to Critical Care Specialties.

 

Compliance Topics:

Time                                                                      

Location                                                               

Unbundling                                                          

NICU Billing                                                                         

NICU Unbundling                                               

Physician E&M Codes

 

Recommended Audience: Physician Office Staff, Physicians-Employed

 

 

Physician Documentation 5: Cardiology Specialty Guidelines                                                               

 

This course contains additional information on compliance rules and regulations specific to Cardiology Specialties.

 

Compliance Topics:

Myocardial Perfusion Imaging                        

Global Surgical Services

Unbundling                                                          

National Correct Code Initiatives (NCCI)

Cardiac Catheterizations                                  

EKGs

Pulse Oximetry                                                   

Ventilation Management

Modifer Uses                                                       

Modifer 25, 59

Critical Care                                                        

Time

Physician E&M Codes                                       

 

Recommended Audience: Physician Office Staff, Physicians-Employed

 

 

Physician Documentation 6: Surgery Specialty Guidelines                                                                    

 

This course contains additional information on compliance rules and regulations specific to Surgery Specialties.

 

Compliance Topics:

PATH                                                                    

Co-Surgery

Assistant at Surgery                                           

Unbundling

Modifier Use/Abuse                                           

Pulse Oximetry

Ventilation Management                                  

Critical Care

Time                                                                      

Global Surgical Package

Physician E&M Codes                                       

 

Recommended Audience: Physician Office Staff, Physicians-Employed

 

 

Physician Documentation 7: Psychiatry Specialty Guidelines                                                              

 

This course contains additional information on compliance rules and regulations specific to Psychiatry Specialties.

 

Compliance Topics:

Medical Necessity

Upcoding                                                             

Psychotherapy with Medical E&M

Unbundling                                                          

Time

Batch Documentation                                        

Group Psychotherapy

Psychological Testing                                       

“Incident To” Billing

Clinical Psychologist Services                         

Clinical Social Workers/Services    

Psychiatric Diagnostic Interview                      

Diagnostic Coverage Limitations

Diagnostic Documentation Requirements

Physician E&M Codes

 

Recommended Audience: Physician Office Staff, Physicians-Employed

 

 

Physician Documentation 8: Nephrology Specialty Guidelines                                                             

 

This course contains additional information on compliance rules and regulations specific to Nephrology Specialties.

 

Compliance Topics:

PATH                                                                    

Unbundling

Dialysis                                                                 

Monthly Capitation Payment

Modifier Use                                                        

Physician E&M Codes/Consultations

 

Recommended Audience: Physician Office Staff, Physicians-Employed

 

 

Physician Documentation 9: Family Practice & Internal Medicine Specialty Guidelines                   

 

This course contains additional information on compliance rules and regulations specific to Family Medicine & Internal Medicine Specialties.

 

Compliance Topics:

PATH                                                                    

Preventive Medicine Services         

Modifier Use

EKG/Radiology                                   

Unbundling

Pulse Oximetry                                   

Ventilation Management

Critical Care                                        

Time

NICU Billing                                         

Physician E&M Codes

 

Recommended Audience: Physician Office Staff, Physicians-Employed

 

 

EMTALA : The Basics (Core Module)                                                                                                          

 

The Core EMTALA module will address the definition of an Emergency Medical Condition, EMTALA requirements, and applying EMTALA at your facility. This course will identify the basic requirements of EMTALA, name at least three instances when the EMTALA obligation for a hospital ends, define “Medical Screening Examination”, describe a situation when an unstable patient may be transferred to another facility, and identify many of the compliance issues related to EMTALA.

 

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

When EMTALA Begins

EMTALA Applicability to Requests for Care

Outpatient Services

EMTALA and Inpatient Services

When does EMTALA End

 

Recommended Audience: General Staff (Non-Emergency Department, Non-Physicians, Non-Management)

 

 

EMTALA: Combined Module                                                                                                                        

 

The Combined EMTALA module will cover the MSE, stabilization and transfers, documentation required under EMTALA, the applicability of EMTALA at other facilities, on-call coverage, and EMTALA investigations. The module will define “Medical Screening Examination”, list the qualified individuals capable of providing the MSE, understand the requirements for stabilization and transfer, understand the documentation requirements under EMTALA, identify entities affected by EMTALA, understand on-call coverage requirements, and list potential sources of EMTALA allegations.

 

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

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

Physician Benefits of On-Call Coverage

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

 

Recommended Audience: Managers, ED Physicians, ED Personnel, Urgent Care and Provider-Based Staff

 

 

EMTALA 1: Medical Screening Examination (Supplemental Module)                                                    

 

This course is intended for all ED personnel and addresses the requirements of and issues associated with the MSE. This supplemental course will cover the aspects of a MSE, define “Medical Screening Examination”, and list the qualified individuals capable of providing the MSE.

 

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: Transfers & Stabilization (Supplemental Module)                                                          

 

This course is intended for all ED personnel and addresses the requirements of and issues associated with transfers and stabilization. This supplemental module we cover Stabilization and Transfers under EMTALA. The course will describe a situation when an unstable patient may be transferred, define a transfer, and list at least three items to document when transferring a patient.

 

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)                                                                               

 

This course is intended for ED personnel, particularly ED physicians and addresses the requirements and issues associated with documentation when EMTALA applies. This supplemental course focuses on appropriate documentation of the MSE, a patient’s refusal of emergency treatment, patient transfer, and the on-call coverage list. The course also covers required EMTALA signage and maintenance of a central log.

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 (Supplemental Module)                                           

 

This course is intended for managers and staff of urgent care and provider-based locations. This course will cover a variety of topics related to applying EMTALA at facilities other than the hospital and it’s on-campus departments. The course will identify the entities affected by EMTALA, provide two examples of “Hospital Property”, and define and identify a “Dedicated Emergency Department”.

 

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)                                                                          

 

This module is intended for ED physicians and managers. This course will describe the type of information that is maintained on a facility’s on-call list, list at least three benefits for physicians who provide on-call services, and identify who is responsible for determining whether the on-call physician must physically see the patient or whether the services can be handled by a non-physician practitioner.

 

Compliance Topics:

Physician Scope of Privileges

On-Call List

Physician On-Call Requirements

Additional On-Call Requirements

Physician Benefits of On-call Coverage

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)                                                                                  

 

This course is intended for managers. EMTALA investigations are performed by the Centers for Medicare and Medicaid Services (CMS) and address policies and processes.  This course will name three situations that may result in an EMTALA investigation, and describe the potential fines and penalties imposed by the OIG for EMTALA violations.

 

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

 

 

HIPAA Compliance - Courseware include Scenarios, Examples & Testing

 

HIPAA 1 for General Staff

                                                                                                           

This course will provide you with important information about the laws and regulations that affect the healthcare industry and your organization. Upon completion of this course, you should: (1) Have a basic understanding of HIPAA-the law that protects patient health information, and (2) Know your reporting obligations if you suspect a privacy violation.

 

HIPAA Compliance Topics:

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

Security-Email & Internet Use Guidelines     

Security-Facility

Security-Breach Notification                                            

Patient Rights Under HIPAA

Reporting

 

 

HIPAA for Management & Physicians

                                                                                               

This course will provide you with important information about the laws and regulations that affect the healthcare industry and your organization. Upon completion of this course, you should be able to: (1) Define PHI and explain how it may be used or disclosed, (2) Describe patient rights with respect to PHI, and (3) Describe the tools used to safeguard PHI.

 

HIPAA Compliance Topics:

Notice of Privacy Practices (NPP)                   

Protected Health Information (PHI)

Texting & Social Media                                                     

Admissions & Registration

Incidental Disclosures                                                       

Patient Care

Security                                                                

Breach Notification

Medical Records                                                 

Administration & Hospital Operations

Document Retention

 

 

HIPAA for Medical Records Personnel-Both Staff & Management

                                                           

This course will provide you with important information about the laws and regulations that affect the healthcare industry and your organization. Upon completion of this course, you should be able to: (1) Understand patient rights: Access, Amendment, Accounting Disclosures, Authorizations, Request for Restrictions, Request for Confidential Communications, and (2) Define PHI and describe the safeguards in place to protect patient information.

 

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 Verification of Identity & Authority      

Disclosures NOT Required to be an Accounting Verification of Identity & Authority

Business Associates                                                          

Security                                                                

Incidental Disclosures

Breach Notifications

 

 

Note:

  • Courses are updated on a regular basis

  • Courses can be further customized to meet organizational requirements

  • Courses have been designed to fit into any Learning Management System (LMS)

  • Courses contain real healthcare scenarios

  • Courses included testing for comprehension

  • Courses can be “bookmarked”

 

 

Healthcare Experience

 

Our Subject Matter Experts are comprised of highly qualified healthcare professionals specializing in regulatory compliance with extensive experience in acute care reimbursement, physician payment, inpatient/outpatient coding and documentation, and financial analysis. Included in this group of professionals are physicians, registered nurses, certified coding specialists, registered records administrators, certified public accountants and attorneys.

For the better part of the last decade, our Subject Matter Experts has been extremely active with investigations and negotiations on behalf of providers with the Department of Justice ("DOJ"), Office of Inspector General ("OIG") and the Federal Bureau of Investigations ("FBI"). Specifically, our Subject Matter Experts have served numerous health industries clients with negotiating corporate integrity agreements ("CIA") and investigation settlements with various state United States Attorney Offices and local OIG offices, as well as serving as the independent review organization ("IRO").

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