Compliance
Compliance Week Two – Compliance Risk Reduction
Every day, a supplier faces a certain amount of “risk” in operating his or her business. To help reduce this risk, here are several areas were risk could occur. Review these areas to ensure your organization is minimizing the risk when billing Medicare. It is recommended that you randomly pull 10-15% of your charts for this review.
Corresponding Standards
ORG 5 – Compliance Program PS 2 – Physician Orders and Coordination of Care PS 3 – Plan of Service PS 4 – Client/Caregiver Education, Training and Safety
PS 6 – Client Medical Records DEL 1 – Delivery Documentation
|Comple|Indicator |Corresponding HQAA |Findings |Action/Outcome |
|te | |Standard | | |
| |Billing for items or services not provided: |PS 6 | | |
| | |DEL 1 | | |
| |Review the client/patient chart for proof of delivery. |PS 6 | | |
| |Proof of delivery must be available and most often kept in the patient’s file. Proof| | | |
| |of delivery can be in the form of a patient/caregiver signature or a tracking number | | | |
| |generated by a delivery service such as UPS or FedEx. If it is not in the chart, it | | | |
| |didn’t happen; therefore, did you just send in a false claim? | | | |
| |Billing for items or services not ordered: |PS 2 | | |
| | |PS 6 | | |
| |Review client/patient chart for current order or prescription. |PS 6 | | |
| |This happens most often when a prescription is not on file; therefore, there is no | | | |
| |proof the physician ever ordered the product(s). Another cause for errors may be | | | |
| |incorrectly entered products in the billing system. | | | |
| |Continuing to bill for rental items after they are no longer medically necessary: |ORG 5 | | |
| | |PS 3 | | |
| |Contact 30 patients with equipment rental of more than 6 months determine if they are| | | |
| |using the equipment and medical necessity is still valid. | | | |
| |Conducting monthly follow ups for all or (a portion—what does a portion mean?) of | | | |
| |current rental patients to determine if the patient is still using the rental | | | |
| |equipment. Medicare’s position is that it is the responsibility of the supplier to | | | |
| |determine if medical necessity continues to be valid. | | | |
| |Capped rentals: |ORG 5 | | |
| |Audit 10 charts where the patient is renting equipment in the capped rental |ORG 5 | | |
| |category. Choose varying months of rental and check to ensure the correct modifier |PS 4 | | |
| |was used. Refer to your Medicare supplier manual for more information regarding | | | |
| |capped rentals. | | | |
| |The correct modifiers must be included during a specific month of rental. While | | | |
| |Medicare’s claims processing system can track capped rentals (that’s how violators | | | |
| |are caught), it is the supplier’s responsibility to track capped rental equipment. | | | |
| |Delivering or billing for certain items or supplies prior to receiving a physician's |PS 6 | | |
| |order and/or appropriate CMN: | | | |
| |Check the written prescription found in the patient chart and match the date to the |PS 6 | | |
| |date of delivery. The prescription date must precede or be equal to the date of |DEL 1 | | |
| |delivery. | | | |
| |Items include, but are not limited to TENS units, multiple types of pressure pads and| | | |
| |cushions, various wheelchairs and accessories, scooters and power wheelchairs, and | | | |
| |powered seat- lift mechanisms. For a complete list of items needing a written order | | | |
| |before delivery, please refer to your regional supplier manual. | | | |
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