HEAT Provider Compliance Training Videos

https://www.youtube.com/user/OIGatHHS

http://oig.hhs.gov/authorities/docs/physician.pdf

Compliance Program

Goal:  The goal of the compliance program is to provide a tool that strengthens the efforts of health care providers to prevent and reduce fraud and improper conduct.

Part 1:  Conducting internal monitoring and auditing through the performance of periodic audits

Chart reviews will occur at discharge and at other times during the course of treatment.  Each clinician will be assigned one peer chart review quarterly.  The following will be reviewed for accuracy:

  • Current physician order.

and/or

  • Current authorization.
  • Parent intake packet with appropriate signatures
  • Current ROI signed within 12 months of review.
  • Each billed evaluation has a report.

and/or

  • Evaluations done at another agency are in chart. POT is written from this evaluation.
  • Each authorization period has a progress note and physician order.
  • Each billed eval and tx visit per patient ledger has an eval or tx note with appropriate signatures.
  • Each cancelled or no show tx note has a tx note with appropriate signatures indicating cancellation or no show and reason why.  Also put reason if known and whether a letter or phone call was placed.
  • Discharge Summary if patient has been discharged.

Please use chart review form for specific items to be reviewed.

 Chart Review

Clinician Name:

 

Patient’s Name:

 

Is there a …

___Parent Packet with Signatures

___ROI with Signatures

___HIPAA document with Signatures

___PO and/or Authorizations are current

___IFSP (birth to 3) if applicable

Treatment Note:

Child’s Name                                         Clinician’s Signature with Credentials

Treatment in Minutes                              Co Signature if Applicable

Long and Short Term Goals                   Progress Towards Goal (percentage or fraction)

Baseline                                                Date of Service

Intervention/Materials                             Completed in Ink

Caregiver Education                              EISC Present

All boxes completed                             Notes in Chronological Order

Narrative (what short term goals addressed and intervention used by the clinician, how the patient responded, what the clinician did to modify or improve the patient response, how the patient responded, what goals will be targeted or the focus of the next therapy session)

Notes match visits billed

MID (if Medicaid)                                   Place of Service Code

CPT code                                             Prognosis

Prior approval dates                              Frequency/Duration

 

Comments:

 

Evaluation:

Child’s Name                                         Date Signed

Child’s Age                                           Clinician’s Signature with Credentials

Severity/Tx Diagnosis                            Long Term Goals

Frequency/Duration                               Short Term Goals with Baseline and Intervention

Future Progress Term                            Tests Admin with SS and AE

Correct Dates                                        Prior Dates Tests Admin with SS/AE, Location

Recommendations                                Evaluation date match visit billed

MID (if Medicaid)                                   Place of Service Code

CPT code                                             Prognosis

Diagnosis (statement of the problem, treatment diagnosis, medical diagnosis)

Physician’s order for evaluation

Comments:

 

Progress Note:

Child’s Name                                         Date Signed

Child’s Age                                           Clinician’s Signature with Credentials

Severity/ Tx Diagnosis                           Long Term Goals

Frequency/Duration                               Short Term Goals with Baseline and Intervention

Future Progress Term                            Current Progress Term

Updated testing                                                Current Recommendations

Continue Goal/Goal Met                         Prior Dates Tests Admin with SS/AE, Location   MID (if Medicaid)                                   Place of Service Code

CPT code                                             Prognosis

Diagnosis (statement of the problem, treatment diagnosis, medical diagnosis)

Physician’s order covering progress term

Overall narrative summary of tx course with discussion of progress, interventions used, clinician’s response to obtain the intended outcome and patient responses.

 

 

Comments:

 

 

Plan of Treatment:

Child’s Name                                         Date Signed

Child’s Age                                           Clinician’s Signature with Credentials

SeverityTx /Diagnosis                            Long Term Goals

Frequency/Duration                               Short Term Goals with Baseline and Intervention

Future Progress Term                            Prior Dates Tests Admin with SS/AE, Location

Current Recommendations

MID (if Medicaid)                                   Place of Service Code

CPT code                                             Prognosis

Diagnosis (statement of the problem, treatment diagnosis, medical diagnosis)

Physician’s order covering progress term

 

 

Comments:

 

Discharge Summary:

Child’s Name                                         Date Signed

Child’s Age                                           Clinician’s Signature with Credentials

Severity/Tx Diagnosis                            Long Term Goals

Frequency/Duration                               Short Term Goals with Baseline and Intervention             Continue Goal/Goal Met                               Prior Dates Tests Admin with SS/AE, Location

Reason for Discharge                            Progress Towards Goals

Date of Discharge

CPT code                                             Prognosis

Diagnosis (statement of the problem, treatment diagnosis, medical diagnosis)

Physician’s order covering progress term

Overall narrative summary of tx course with discussion of progress, interventions used, clinician’s response to obtain the intended outcome and patient responses.

 

Comments:

 

Monthly Summary:

All applicable fields complete

Procedure code is correct

IFSP outcomes match the IFSP

Dates of CA and NS included in the body

EISC present included in body

Signature and Cosignature present

Discharge indicated in body

MID (if Medicaid)

Place of Service Code

 

 

 

Comments:

 

Reviewer:

Clinician’s Signature:

Date Clinician Reviewed Findings:

Implemented:  10/16/12

Revision:  2/11/13

Revision:  6/5/13

Part 2:  Implementing compliance and practice standards through the development of written standards and procedures.

Coding and Billing

Therapy Playground does not bill for services until the therapist has submitted the appropriate billing code, treatment diagnosis code and documentation to the office staff.  The office staff then bills for the service as outlined by the providing therapist, making sure the documentation support the service billed.  When the remittance is received, the office staff then ensures the appropriate code was billed and paid for.  Any billing errors will be reported to the insurance company within 60 days of the error being found by office staff.

Provider Numbers

Upon employment, each provider will fill out the appropriate insurance credentialing forms.  Services will not be billed under this provider until the credentialing process is complete and identification numbers are received from the insurance company.

Medical Necessity for Treatment

Therapy Playground has decided that all documents must adhere to the Medicaid Guidelines for Documentation.  We know many of our patients do not have Medicaid, but we never know when Medicaid will be the secondary insurance. Therefore, it is in our best interests to include all the items Medicaid requires in our documents.

 

The guideline can be read in its entirety at

http://www.ncdhhs.gov/dma/mp/8f.pdf

The following are the highlights of what you need to know.

Medical Necessity for Motor Treatment

  • The motor evaluation must follow the AOTA and the APTA guidelines for beginning, continuing and terminating treatment.

 

Medical Necessity for Language Treatment

  • Mild Delay – Therapy is recommended once a week
    • SS of 78 – 85
    • Percent Delay of 20 – 24%
    • Percentile Rank of 7th  – 15th
    • Additional documentation of functional impairment of pragmatics
  • Moderate Delay – Therapy is recommended twice a week
    • SS of 70 – 77
    • Percent Delay of 25 – 29%
    • Percentile Rank of 2nd – 6th
    • Additional documentation of functional impairment of pragmatics
  • Severe Delay – Therapy is recommended twice a week
    • SS of 69 or lower
    • Percent Delay of 30% or more
    • Percentile Rank below 2nd percentile
    • Additional documentation of functional impairment of pragmatics

Medical Necessity for Articulation/Phonology Treatment

  • Mild Delay – Therapy is recommended once a week
    • SS of 78 – 85
    • One phonological process that is not developmentally appropriate with a 20% occurrence.
    • Percentile Rank of 7th  – 15th
    • Additional documentation to include stimuability, percent consonant correct measures, intelligibility.
    • The child is expected to have few articulation errors, generally characterized by typical omissions, substitutions, and/or distortions.  Intelligibility is not greatly affected, but errors are noticeable.
  • Moderate Delay – Therapy is recommended twice a week
    • SS of 70 – 77
    • One phonological process that is not developmentally appropriate with a 21 – 40% occurrence.
    • Two or more phonological process that is not developmentally appropriate with a 20% occurrence.
    • Percentile Rank of 2nd – 6th
    • Additional documentation to include stimuability, percent consonant correct measures, intelligibility.
    • The child typically has 3 – 5 sound in error, which are one year below expected development. Error patterns may be atypical.  Intelligibility is affected, and conversational speech is occasionally unintelligible.
  • Severe Delay – Therapy is recommended twice a week
    • SS of 69 or lower
    • One phonological process that is not developmentally appropriate with a 40% or more occurrences.
    • Three or more phonological process that is not developmentally appropriate with a 20% occurrence.
    • Percentile Rank below 2nd percentile
    • Additional documentation to include stimuability, percent consonant correct measures, intelligibility.
    • The child typically has 5 or more sounds in error with a combination of error types. Inconsistent errors and lack of stimuability is evident. Conversational speech is generally unintelligible.

 

Articulation Treatment Goals Based on Age of Acquisition

Age of Acquisition                               Treatment Goal(s)

Before Age 2                                       Vowel sounds

After Age 2, 0 months                         /m/, /n/, /h/, /w/, /p/, /b/

After Age 3, 0 months                         /f/, /k/, /g/, /t/, /d/

After Age 4, 0 months                         /n/, /j/

After Age 5, 0 months                         voiced th, sh, ch, /l/, /v/, j

After Age 6, 0 months                         /s/, /r/, /z/, /s/ blends, /r/ blends, vowelized /r/,

voiceless th, /l/ blends

 

In using these guidelines for determining eligibility, total number of errors and intelligibility should be considered. A 90% criterion is roughly in accord with accepted educational and psychometric practice that considers only the lowest 5% – 10% of performances on a standardized instrument to be outside the normal range.

Phonology Treatment Goals Based on Age of Acquisition of Adult Phonological

Rules

Age of Acquisition Treatment Goal(s)

After age 2 years, 0 months                           Syllable reduplication

 

After age 2 years, 6 months                           Backing, deletion of initial consonants, metathesis, labialization, assimilation

 

After age 3 years, 0 months                           Final consonant devoicing, fronting of palatals and velars, final consonant deletion, weak syllable deletion /syllable reduction, stridency deletion/stopping, prevocalic voicing, epenthesis

 

When children develop idiosyncratic patterns, which exist after age 3 years, 0 months to 3 years, 5 months, they likely reflect a phonological disorder and should be addressed in

therapy.

 

Minor processes, or secondary patterns such as glottal replacement, apicalization and palatalization typically occur in conjunction with other major processes. These minor processes frequently correct on their own as those major processes are being targeted.

 

After age 4 years, 0 months                           Deaffrication, vowelization

 

 

 

Eligibility Guidelines for Stuttering

Borderline/Mild                                    3 – 10 sw/m or 3% – 10% stuttered words of words spoken, provided that prolongations are less than 2 seconds and no struggle behaviors and that the  number of prolongations does not exceed total whole word and part-word repetitions. Once a week recommended.

 

Moderate                                             More than 10 sw/m or 10% stuttered words of words spoken, duration of dysfluencies up to 2 seconds; secondary characteristics may be

present. Twice a week recommended.

 

Severe                                                More than 10 sw/m or 10% stuttered words of words spoken, duration of dysfluencies lasting 3 or more seconds, secondary characteristics are conspicuous. Twice a week recommended.

 

Note: When the percentage of stuttered words fall in a lower severity rating and duration and/or presence of physical characteristics falls in a higher severity rating, the service delivery may be raised to the higher level.

 

Differential Diagnosis for Stuttering

Characteristics of normally dysfluent children:

• Nine dysfluencies or less per every 100 words spoken.

• Majority types of dysfluencies include: whole-word, phrase repetitions, interjections, and revisions.

• No more than two unit repetitions per part-word repetition (e.g., b-b-ball, but not b-b-b ball.).

• Schwa is not perceived (e.g., bee-bee-beet. is common, but not buh-buh-buh-beet).

• Little if any difficulty in starting and sustaining voicing; voicing or airflow between

units is generally continuous; dysfluencies are brief and effortless.

 

The following information may be helpful in monitoring children for fluency disorders:

 

This information indicates dysfluencies that are considered typical in children, crossover behaviors that may be early indicators of true stuttering and what characteristics are typical of true stutterers.

More Usual (Typical Dysfluencies)

• Silent pauses; interjections of sounds, syllables or words; revisions of phrases or sentences; monosyllabic word repetitions or syllable repetitions with relatively even rhythm and stress; three or less repetitions per instance; phrase repetitions.

Crossover Behaviors

• Monosyllabic word repetitions or syllable repetitions with relatively even stress and rhythm but four or more repetitions per instance, monosyllabic word repetitions or syllable repetitions with relatively uneven rhythm and stress with two or more repetitions per instance.

More Unusual (Atypical Dysfluencies)

• Syllable repetitions ending in prolongations; sound, syllable or word prolongations; or prolongations ending in fixed postures of speech mechanism, increased tension noted in the act.

 

Augmentative and Alternative Communication (AAC) standards for treatment from ASHA Augmentative Communication Strategies, volume II, 1988:

a. These criteria define parameters for involvement and services of the therapist for evaluation and treatment, not purchases of the devices or equipment.

b. These criteria are not intended to override or replace existing limits on coverage for services, either as dollar amounts or as acceptable billing codes.

“The primary purpose of an augmentative communication program is to enhance the quality of life for persons with severe speech and language impairments in accordance with each person’s preferences, abilities, and life style. Augmentative communication programs perform the continuing, vital, and unique task of helping these individuals develop communication skills they will need throughout the course of their lives. The programs also encourage the development of each individual’s initiative, independence, and sense of personal responsibility and self-worth.”

 

AAC treatment programs are developed in accordance with Preferred Practices approved by ASHA. These services include:

a. Counseling.

b. Product Dispensing.

c. Product Repair/Modification.

d. AAC System and/or Device Treatment/Orientation.

e. Prosthetic/Adaptive Device Treatment/Orientation.

f. Speech/Language Instruction .

 

AAC treatment codes are used for the following:

a. Therapeutic intervention for device programming and development.

b. Intervention with family members/caregivers/support workers, and individual for functional use of the device.

c. Therapeutic intervention with the individual in discourse with communication partner using his/her device.

The above areas of treatment need to be performed by a licensed Speech-Language Pathologist with education and experience in augmentative communication to provide therapeutic intervention to help individuals communicate effectively using their device in all areas pertinent to the individual. Treatment will be authorized when the results of an authorized AAC assessment recommend either a low-tech or a high-tech system.

 

Possible reasons for additional treatment include:

a. Update of device.

b. Replacement of current device.

c. Significant revisions to the device and/or vocabulary.

d. Medical changes.

 

Aural Rehabilitation Practice Guidelines

The basis for audiology referral is the presence of any degree or type of hearing loss on  the basis of the results of an audiologic (aural) rehabilitation assessment or presence of impaired or compromised auditory processing abilities on the

basis of the results of a central auditory test battery.

Examples of deficits for initiating therapy may include, but are not limited to,

the following:

a. Hearing loss (any type) >25 dBHL at 2 or more frequencies in either ear.

b. Standard Score more than 1 SD (standard deviation) below normal for chronological age on standardized tests of language, audition, speech, or auditory processing.

c. Impaired or compromised auditory processing abilities as documented on the basis of the results of a central auditory test battery.

d. Less than 1-year gain in skills (auditory, language, speech, processing) during a 12-month period of time.

 

Underlying Referral Premise

Aural rehabilitation will:

a. facilitate receptive and expressive communication of recipients with hearing loss, and/or

b. achieve improved, augmented or compensated communication processes, and/or

c. improve auditory processing, listening, spoken language processing, overall communication process, and/or

d. benefit learning and daily activities.

 

Evaluation—Audiologic (Aural) Rehabilitation

Service delivery requires the following elements:

Note: Functioning of hearing aids, assistive listening systems/devices, and sensory aids must be checked prior to the assessment.

Through interview, observation, and clinical testing, evaluate (in both clinical and natural environments):

a. Client history.

b. Reception, comprehension, and production of language in oral, signed or written modalities.

c. Speech and voice production.

d. Perception of speech and non-speech stimuli in multiple modalities.

e. Listening skills.

f. Speech reading.

g. Communication strategies.

 

Kickbacks and Self Referrals

 

Therapy Playground cannot self refer for physical, occupational or speech therapy.  All referrals require a physician’s order.  The patient’s family and the prescribing physician will make the determination what agency the referral will go to.

 

Employees of Therapy Playground do not give or accept gifts of more than $25.00.

 

Retention of Records

All records will be kept at a Therapy Playground facility for a period of 7 years from the last date of service.

 

Medical records will be kept in a file folder in a locked file cabinet if on paper.  Electronic medical records will be kept on a secure server with password protection and appropriate user rights.

 

In the event the practice closed, the owner will continue to pay for the phone line and will be the point of contact for all medical records.  In the event the practice is sold, the new owners will be the point of contact for all medical records.

 

Part 3:  Designating a compliance officer to monitor compliance efforts and enforce practice standards

 

The compliance officer for Therapy Playground is Jennifer Dibb.  The compliance officer is responsible for the following:

  • Overseeing and monitoring the implementation of the compliance program.
  • Establishing methods such as periodic audits to improve the practices efficiency and quality of service and to reduce the practices vulnerability to fraud and abuse.
  • Periodically revising the compliance program in light of changes in the needs of the practice or changes in law.
  • Developing, coordinating and participating in a training program that focuses on the components of the compliance program, and seeks to ensure the training materials are appropriate.
  • Investigating any report of allegation concerning possible unethical or improper business practices and monitoring subsequent corrective action and /or compliance.
  • Ensuring that the OIG list of excluded individuals have been checked with respect to all employees, medical staff and independent contractors.

 

As documented in the February 2012 Medicaid Bulletin, Therapy Playground will adhere to the following:

Medicaid Providers Must Screen for Individual & Entity Exclusion

The HHS Office of Inspector General (HHS-OIG) excludes individuals and entities from participation in Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), and all Federal health care programs (as defined in section 1128B(f) of the Social Security Act based on the authority contained in various sections of the Act, including sections 1128, 1128A, and 1156.

When the HHS-OIG has excluded a provider, Federal health care programs (including Medicaid and SCHIP programs) are generally prohibited from paying for any items or services furnished, ordered, or prescribed by excluded individuals or entities. (Section 1903(i)(2) of the Act; and 42 CFR section 1001.1901(b)). This payment ban applies to any items or services reimbursable under a Medicaid program that are furnished by an excluded individual or entity, and extends to:

  • all methods of reimbursement, whether payment results from itemized claims, cost reports, fee schedules, or a prospective payment system;
  • payment for administrative and management services not directly related to patient care, but that are a necessary component of providing items and services to Medicaid recipients, when those payments are reported on a cost report or are otherwise payable by the Medicaid program; and
  • payment to cover an excluded individual’s salary, expenses or fringe benefits, regardless of whether they provide direct patient care, when those payments are reported on a cost report or are otherwise payable by the Medicaid program.

In addition, no Medicaid payments can be made for any items or services directed or prescribed by an excluded physician/pharmacist or other authorized person when the individual or entity furnishing the services either knew or should have known of the exclusion. This prohibition applies even when the Medicaid payment itself is made to another provider/pharmacist, practitioner or supplier that is not excluded. (42 CFR Section 1001.1901(b).

Providers can look for excluded Individuals & Entities on the HHS-OIG List of Excluded Individuals and Entities (LEIE) database, which is accessible to the general public and displays information about parties excluded from participation in Medicare, Medicaid, and all other Federal health care programs. The LEIE website is located at:https://www.oig.hhs.gov/fraud/exclusions.asp.

To further protect against payments for items and services furnished, prescribed or ordered by excluded individuals and/or entities, the Division of Medical Assistance (DMA) is advising all current providers and providers applying to participate in the Medicaid program to take the following steps:

  • Provider has an obligation and must screen all employees and contractors to determine whether any of them have been excluded.
  • DMA will require this obligation as a condition of enrollment into the Medicaid program.
  • Search the HHS-OIG website monthly by the names of an individual or entity to capture exclusions and reinstatements that have occurred since the last search.
  • Immediately report to the appropriate Regional Office of the OIG Office of Investigations or DMA any exclusion information discovered.

This line of defense in combating fraud, waste & abuse must be conducted accurately, thoroughly and routinely.  DMA understands that providers share our commitment to combating fraud, waste & abuse. Working together will strengthen efforts to identify excluded parties.  The integrity and quality of the Medicaid program will be improved which will benefit Medicaid recipients and North Carolina taxpayers.

Program Integrity
DMA, 919-647-8000

 

 

Part 4:  Conducting appropriate training and education on practice standards and procedures

 

Therapy Playground has a training and education program for ensuring business practices in the areas of compliance and in coding and billing training.  This training will occur under the direction of the compliance officer and their designees.

 

  1. Compliance Training

All employees and contractors of Therapy Playground will receive compliance training.  Training will be a combination of self study, webinars and direct instruction.  Training will occur during the orientation phase of employment with Therapy Playground.  Subsequent training will occur when there are policy and procedure updates and/or yearly as needed.  Compliance is a condition of employment.  If employees and contractors do not adhere to the compliance policies, they will be terminated.

 

Compliance training

 

Coding and Billing Training

  • Each office staff member responsible for authorizations and billing will receive training in the following areas:
    • Coding requirements
    • Claim development and submission processes
    • Signing a form for a physician without the physician’s authorizations
    • Proper billing standards and procedures and submission of accurate bills for services or items rendered to federal health care program beneficiaries
    • The legal sanctions for submitting deliberately false or reckless billing.

 

Part 5:  Responding appropriately to detected violations through the investigation and allegations and the disclosure of incidents to appropriate government entities

Upon receipt of a report or reasonable indications of a suspected noncompliance, it is important that the compliance officer look into the allegations to determine whether a violation of applicable law or requirements of the compliance program has occurred.  If so, decisive steps will be taken to correct the problem.  The compliance officer will interview the provider, the family of the patient and any other professionals involved in the care of the patient to determine if noncompliance has occurred.

  • For potential criminal violations, Therapy Playground will contact the OIG as well as Medicaid or Tricare to alert them to the suspected noncompliance.
  • For overpayment issues, Therapy Playground will take action once the overpayment has been identified and alert the insurance company.  Prompt repayment will occur based on the timetable of the insurance company.
  • The compliance officer will make a determination whether the person who has violated the compliance policy should be retrained, disciplined or terminated.

 

Part 6:  Developing open lines of communication to keep practice employees updated regarding compliance activities

At Therapy Playground, there is an open door policy between all employees and contractors and the compliance officer.  The compliance officer meets with all employees monthly and talks about their concerns.  Employees and contractors will be encouraged to report conduct believed to be erroneous or fraudulent.  Employees and contractors will be made aware that failure to report is a violation of the compliance policy.  All reports will be anonymous and held in the strictest of confidence.  There will be no retribution for reporting erroneous or fraudulent behavior. The compliance officer will make a determination once all the facts are investigated and the appropriate agencies contacted.

 

Part 7:  Enforcing disciplinary standards through well publicized guidelines

At Therapy Playground, the compliance officer will complete the compliance investigation summary and make appropriate follow up recommendations on a case by case basis.

 

Implemented:  6/25/13

Fraud and Compliance – August 2013

Jenn discusses insurance fraud and compliance training.  A must-see.

https://therapyplayground.com/oig
The goal of the compliance program is to provide a tool that strengthens the efforts of health care providers to prevent and reduce fraud and improper conduct.
Part 1: Conducting internal monitoring and auditing through the performance of periodic audits
Part 2: Implementing compliance and practice standards through the development of written standards and procedures.
Part 3: Designating a compliance officer to monitor compliance efforts and enforce practice standards
Part 4: Conducting appropriate training and education on practice standards and procedures
Part 5: Responding appropriately to detected violations through the investigation and allegations and the disclosure of incidents to appropriate government entities
Part 6: Developing open lines of communication to keep practice employees updated regarding compliance activities
Part 7: Enforcing disciplinary standards through well publicized guidelines