Operating Policy and Procedure
HSC OP: 52.07, Billing Compliance Plan
PURPOSE: The purpose of the Billing Compliance Plan (hereto referred to as “Plan”) is to implement a Billing Compliance Program (BCP) to provide a framework for effective billing compliance. The Plan encompasses the clinical billing activities within the Schools of Medicine, School of Nursing, School of Pharmacy and School of Health Professions at Texas Tech University Health Sciences Center (TTUHSC) campuses.
REVIEW: This HSC Operating Procedure (OP) will be reviewed each even-numbered year (ENY) by the Chief Compliance Officer (CCCO) and/or Managing Director (Director) of Billing Compliance, and each campus’ Billing Compliance Advisory Committees (BCAC). Finalized OP will be forwarded to the Institutional Compliance Risk Committee (ICRC) for approval by September 1.
POLICY AND PROCEDURE:
1. Defined Terms
The following terms are defined for purposes of this HSC OP:
a. Employees are Faculty, Residents, and Staff who receive W-2 wages from TTUHSC who provide health care services/items, and/or participate in health care operations, including, but not limited to administrative support, preparation of health care claims, billing of health care items/services or similar activities.
b. Agents are individuals and entities that have contracted with TTUHSC to provide health care services/items or otherwise participate in health care operations, including, but not limited to administrative support, preparation of clinical claims, billing of health care items/services or similar activities.
c. Providers are Employees and Agents of the TTUHSC School of Medicine, School of Nursing, School of Health Professions, or School of Pharmacy who engage or participate in the provision of health care services/items billed under a TTUHSC Federal Tax Identification Number. This term includes (but is not limited to) Physicians, Advanced Practice Nurses, Physicians’ Assistants, Speech-Language Pathologists, Audiologists, Clinical Pharmacists, and Clinical Psychologists. This term excludes Residents.
d. Residents are individuals who participate in a TTUHSC-approved graduate medical education (GME) program. This term includes Interns and Fellows in GME programs recognized as approved for purposes of direct GME payments made by a Medicare Contractor.
e. Fraud has the same meaning as contained in TTUS Regents’ Rule 07.03, Fraud Policy.
f. Violation of Law means failure or refusal to follow any applicable state or federal law such that criminal and/or civil penalties may be imposed.
g. Non-compliance means failure or refusal to follow applicable state or federal laws or institutional policies whether or not such conduct results in financial risk to TTUHSC. It can include acts that constitute fraud, violations-of-law, or failure to comply with the Plan or related policies and procedures.
h. Proxy refers to an individual, appointed and approved in advance, to function as the designated BCAC member’s representative to be utilized in instances where the BCAC member is unable to attend the BCAC function.
i. BCAC – Regional Billing Compliance Advisory Committee at each campus as applicable.
j. BCO – Regional Billing Compliance Officer at each campus as applicable.
k. CCO – Chief Compliance Officer
l. BCP – Billing Compliance Program
m. ICC – Institutional Compliance Committee, i.e. TTUHSC President’s Cabinet
n. ICRC - Institutional Compliance Risk Committee; appointed by the TTUHSC ICC
o. Director – Managing Director of Billing Compliance
p. External Investigations – investigations initiated by CMS, CMS OIG, DOJ, Texas Medicaid, other government agencies
q. Monitoring – ongoing efforts to determine practices and processes are working as intended to mitigate compliance risks.
Auditing – examination and verification of practices and processes to evaluate compliance with policies and procedures, and state and federal regulations.
2. Billing Compliance Oversight
Billing Compliance Staff. Each School shall provide adequate resources and authority to the Chief Compliance Officer (CCO) to implement an effective BCP. Billing Compliance staff includes the Managing Director, Billing Compliance Officers and Documentation and Coding Auditors.
Chief Compliance Officer (CCO). The CCO shall report to the Institutional Compliance Risk Committee (ICRC) and Institutional Compliance Committee (ICC) on the implementation and effectiveness of the BCP. Specific duties and responsibilities of the CCO shall be outlined in billing compliance policies and procedures.
Managing Director of Billing Compliance (Director). The Director is responsible for billing compliance functions at TTUHSC campuses, and reports to the CCO.
Regional Billing Compliance Officers (BCOs). The BCOs shall be responsible for billing compliance oversight at their respective campus. Specific duties and responsibilities of the BCOs (and their staff as applicable) shall be outlined in billing compliance policies and procedures.
Regional Billing Compliance Advisory Committees (BCAC). Billing Compliance oversight for the TTUHSC Schools of Medicine, Nursing, Health Professions and Pharmacy on each regional campus as applicable shall be provided by a Regional Billing Compliance Advisory Committee (BCAC). The BCAC, and any subcommittees or workgroups established by the BCAC, shall each be considered a “medical committee” as defined under Texas Health and Safety Code §161.031(a), and/or other applicable state and federal laws. All documents generated by the BCAC, submitted to the BCAC or created for the purposes of fulfilling the BCAC’s duties under TTUHSC’s BCP are confidential and privileged and shall be identified as a “Confidential – Medical Committee Document.”
1) Membership. The Schools of Medicine Dean and Regional SOM Deans shall appoint members to the BCAC at their respective campuses as applicable, to include, at a minimum the following:
• the Dean/Regional Dean or his/her designee,
• the Regional Medical Practice Income Plan (MPIP) Director or his/her designee,
• the Medical Records Manager and/or a representative from Electronic Health Record/Electronic Medical Record (ex-officio), and
• other individuals based on recommendations from the CCO, Director and/or BCO.
The Director, Regional BCO and Billing Compliance Auditors (as applicable) shall be ex-officio members of their respective BCAC. BCAC membership may vary between campuses.
2) Meetings. The BCAC meetings are scheduled quarterly, or more often as necessary to meet its responsibilities under the Plan, with the objective of meeting a minimum of three times per year. The Director or BCO shall chair the meetings. In either the Director’s or BCO’s absence, the Billing Compliance Senior Auditor or the CCO may serve as chair. The presence of a simple majority of members shall constitute a quorum for purposes of conducting business. If a quorum is not present, the meeting may proceed to provide information, but no business (i.e., voting) may be conducted.
3) Role and Responsibilities. Each BCAC is responsible for oversight of the Plan at its regional campus as applicable. Each campus BCAC shall, with respect to billing compliance oversight at its campus:
a) Receive reports on the status of the BCP and related activities.
b) Recommend and/or approve corrective action based on the findings from routine monitoring, risk-based audits, and/or investigations.
c) Provide guidance regarding proposed institutional billing compliance policies and procedures, and on issues not covered under existing policies or requiring the attention of the CCO and/or Director.
d) Approve Billing Compliance Policies & Procedures.
e) Assist in identifying risk areas and high risk activities.
f) Provide support in carrying out the various aspects of the BCP, including corrective action.
g) Verify that appropriate billing compliance education and training has been provided.
3. Other Billing Compliance Areas
a. Policies & Procedures. The Director, BCOs, and BCACs shall develop, update and maintain billing compliance policies and procedures addressing billing compliance standards, identified risks and operational procedures. The Plan and related policies shall be posted on the TTUHSC Billing Compliance website at http://www.ttuhsc.edu/compliance/billing/default.aspx.
b. Education and Training.
1) Initial and on-going billing compliance education and training programs shall be developed to address fraud, waste and abuse, and identified billing compliance risk areas.
2) Billing compliance education is provided to designated providers and staff in the TTUHSC Schools of Medicine, Nursing, Pharmacy and Health Professions. Billing Compliance policy 2.2 Education, Billing Compliance.
3) Billing compliance education materials (electronic and/or hard copy) shall be retained at least ten (10) years.
c. Monitoring, Auditing and Investigations
1) Monitoring and Auditing, Routine monitoring and auditing shall be conducted on risk areas identified in the annual work plan, routine reviews, requested reviews, reported concerns, and/or ad hoc issues based on federal documentation guidelines, and other applicable regulations in accordance with approved billing compliance policies. Monitoring and auditing results shall be reported to each campus BCAC.
2. Billing Compliance Investigations
a) Internal. The CCO, Director and/or BCO shall plan, initiate, and oversee investigations arising from identified or suspected non-compliant billing activity. Results of investigations shall be reported to the affected BCAC.
b) External. Any external investigations related to documentation and/or billing of health care items/services shall be reported to the CCCO as soon as possible. Requests for information from external investigators must be reviewed by the CCO and/or General Counsel.
4. Reporting Responsibilities and Resources
a. An Employee or Agent with a good faith belief that any conduct or practice constitutes non-compliance or violates the BCP has a responsibility to report it using one or more of the steps below:
1) Discuss the issue with their immediate supervisor.
2) Discuss the issue with higher level management, such as the Department Administrator, Department Chair, or Dean.
3) Bring the issue to the attention of the CCO, Director and/or BCO.
4) Make a confidential and/or anonymous report by:
• Calling the Compliance Hotline toll free at (866) 294-9352 or
• Using the confidential reporting website for TTUHSC at www.ethicspoint.com
Reporting responsibilities, protections for good-faith reporters and resources are further described in HSC OP 52.03, Fraud and Misconduct Hotline and HSC 52.04, Report & TTUHSC Internal Investigation of Alleged Violations, Non-Retaliation.
5. Response and Corrective Action
a. Response to Allegations
Allegations of billing non-compliance shall be investigated under the direction of the CCO, Director and/or BCO. Responses to findings of non-compliance may include, but are not limited to:
• Refunding of health care services/items.
• Mandatory re-education of individuals and/or departments.
• Escalating corrective action as listed below in paragraph b.
• Modification of the Plan, related policies and procedures and/or education materials.
In accordance with HSC OP 52.04, TTUHSC Employees and Agents shall cooperate during any billing compliance investigation and shall not alter or destroy any documentation during the course of any internal or external investigation.
b. Corrective Action and Appeal Rights
Failure or refusal to comply with applicable laws and regulations or with the BCP and related policies may result in corrective action. An Employee’s supervisor, Chair, or Dean may also be subject to corrective action when he/she
(i) directs or approves the Employee’s improper actions;
(ii) is aware of the improper actions and fails to correct them, or
(iii) otherwise fails to exercise appropriate supervision.
Corrective action and appeal rights will be addressed in accordance with existing policies including, but not limited to, each Schools’ Faculty Handbook, the School of Medicine Housestaff Policies and Procedures, HSC OP 70.31, Employee Conduct, Coaching, Corrective Action and Termination, and HSC OP 60.01, Tenure and Promotion Policy.
6. Right to Change Policy
TTUHSC reserves the right to interpret, change, modify, amend or rescind this policy in whole or in part at any time to reflect changes in policy and/or law.