The following is an excerpt from the Human & Health Services – Guidelines for 3rd Part Medical Billing Companies
- Program Guidance for Third Party Medical Billing Companies
- 1. Introduction
- A. Benefits of a Compliance Program
- B. Application of Compliance Program Guidance
- II. Compliance Program Elements
- A. Written Policies and Procedures – Part I | Part II
- B. Designation of a Compliance Officer and a Compliance Committee
- C. Conducting Effective Training and Education
- D. Developing Effective Lines of Communication
- E. Enforcing Standards Through Well-Publicized Disciplinary Guidelines
- F. Auditing and Monitoring
- G. Responding to Detected Offenses and Developing Corrective Action Initiatives
- III. Conclusion
C. Conducting Effective Training and Education
1. Initial Training in Compliance
The proper education and training of corporate officers, managers, employees and the continual retraining of current personnel at all levels are significant elements of an effective compliance program. In order to ensure the appropriate information is being disseminated to the correct individuals, the training should be separated into two sessions, depending on the employees’ involvement in the submission of claims for reimbursement. All employees should attend the general session on compliance, while employees whose job primarily focuses on submission of claims for reimbursement should be the participants in the detailed sessions.
In the development of a training program, the billing company should consult with its provider clients to ensure that a consistent message is being delivered and avoid any potential conflicts in the implementation of policies and procedures.
a. General Sessions
As part of their compliance programs, billing companies should require all affected personnel to attend training on an annual basis, including appropriate training in Federal and State statutes, regulations and guidelines, the policies of private payers and training in corporate ethics. The general training sessions should emphasize the organization’s commitment to compliance with these legal requirements and policies.
These training programs should include sessions highlighting the organization’s compliance program, summarizing fraud and abuse statutes and regulations, Federal, State and private payer health care program requirements, coding requirements, the claim submission process and marketing practices that reflect current legal and program standards. The organization must take steps to communicate effectively its standards and procedures to all affected employees, physicians, independent contractors and other significant agents, e.g., by requiring participation in training programs and disseminating publications that explain specific requirements in a practical manner.67 Managers of specific departments or groups can assist in identifying areas that require training and in carrying out such training.68 Training instructors may come from outside or inside the organization. New employees should be targeted for training early in their employment.69
As part of the initial training, the standards of conduct should be distributed to all employees.70 At the end of this training session, every employee, as well as contracted consultants, should be required to sign and date a statement that reflects the employee’s knowledge of and commitment to the standards of conduct.
This attestation should be retained in the employee’s personnel file. For contracted consultants, the attestation should become part of the contract and remain in the file that contains such documentation. Further, to assist in ensuring employees continuously meet the expected high standards set forth in the code of conduct, any employee handbook delineating or expanding upon these standards of conduct should be regularly updated as applicable statutes, regulations and Federal health care program requirements are modified.71 Billing companies should provide an additional attestation in the modified standards that stipulates the employee’s knowledge of and commitment to the modifications.
b. Coding and Billing Training
In addition to specific training in the risk areas identified in section II.A.2, above, primary training to appropriate corporate officers, managers and other billing company staff should include such topics as:
• Specific Government and private payer reimbursement principles; 72
• General prohibitions on paying or receiving remuneration to induce referrals;
• Proper selection and sequencing of diagnoses;
• Improper alterations to documentation;
• Submitting a claim for physician services when rendered by a non-physician (i.e., the ‘‘incident to’’ rule and the physician physical presence requirement);
• Proper documentation of services rendered, including the correct application of official coding rules and guidelines;
• Signing a form for a physician without the physician’s authorization; and
• Duty to report misconduct.
Clarifying and emphasizing these areas of concern through training and educational programs are particularly relevant to a billing company’s marketing and financial personnel, in that the pressure to meet business goals may render these employees particularly vulnerable to engaging in prohibited practices.
2. Format of the Training Program
The OIG suggests all relevant levels of personnel be made part of various educational and training programs of the billing company.73 Employees should be required to have a minimum number of educational hours per year, as appropriate, as part of their employment responsibilities.74 For example, as discussed above, certain employees involved in billing functions should be required to attend periodic training in applicable reimbursement coverage and documentation of records.75 A variety of teaching methods, such as interactive training and training in several different languages, particularly where a billing company has a culturally diverse staff, should be implemented so that all affected employees are knowledgeable about the institution’s standards of conduct and procedures for alerting senior management to problems and concerns.76 Targeted training should be provided to corporate officers, managers and other employees whose actions affect the accuracy of the claims submitted to the Government, such as employees involved in the coding, billing and marketing processes. All training materials should be designed to take into account the skills, knowledge and experience of the individual trainees. Given the complexity and interdependent relationships of many departments, it is important for the compliance officer to supervise and coordinate the training program.
The OIG recommends attendance and participation at training programs be made a condition of continued employment and that failure to comply with training requirements should result in disciplinary action, including possible termination, when such failure is serious. Adherence to the provisions of the compliance program, such as training requirements, should be a factor in the annual evaluation of each employee. The billing company should retain adequate records of its training of employees, including attendance logs and material distributed at training sessions.
3. Continuing Education on Compliance Issues
It is essential that compliance issues remain at the forefront of the billing company’s priorities. The OIG recommends billing company compliance programs address the need for periodic professional education courses for billing company personnel. In particular, the billing company should ensure that coding personnel receive annual professional training on the updated codes for the current year.
In order to maintain a sense of seriousness about compliance in the billing company’s operations, the billing company must continue to disseminate the compliance message. One effective mechanism for maintaining a consistent presence of the compliance message is to publish a monthly newsletter to address compliance concerns. This would allow the billing company to address specific examples of problems the company encountered during its ongoing audits and risk analysis, while reinforcing the company’s firm commitment to the general principles of compliance and ethical conduct. The newsletter could also include the risk areas published by the OIG in its Special Fraud Alerts. Finally, the billing company could use the newsletter as a mechanism to address areas of ambiguity in the coding and billing process. The billing company should maintain its newsletters in a central location to document the guidance offered and provide new employees with access to guidance previously provided.