5 EMS compliance resolutions

By Amanda Ward

The beginning of a new calendar year or fiscal year is a time to reflect on all that we've accomplished in the past year and to set goals for the year to come. This year, resolve to finally implement a compliance program at your agency or jump start your current program.

Remember, the Affordable Care Act mandates that all health care providers have a compliance program in place. Even though the future of the ACA is uncertain, the government's efforts to combat health care fraud and abuse have yielded over $1.5 billion in savings. In other words, even if the law mandating compliance programs is repealed, the government is going to continue to look for Medicare fraud and abuse among health care providers. The best way to ensure your agency avoids trouble is to have an updated, effective compliance program.

While starting a compliance program can seem overwhelming, there are some small changes that can have a major impact on your agency's overall compliance. These five resolutions will get your started on the path to implementing or improving your compliance program.

1. Resolve to designate a compliance officer.

Having a designated compliance officer to operate and monitor the compliance program ensures that Medicare compliance is a top priority for your organization. The compliance officer should be a high-level individual within your agency who reports directly to your top management such as the chief, CEO or board of directors. The goal is to make sure that the top-decision makers have unfiltered, accurate information about the compliance risks affecting your agency.

The compliance officer should be responsible for staying current with Medicare rules and regulations, assessing the agency's risks, overseeing the compliance committee, conducting internal audits and communicating with staff members. While it's not realistic for most EMS agencies to have someone whose only responsibility is to be the compliance officer, ensure that your compliance officer has the time and resources to devote sufficient time to the role.

2. Resolve to conduct regular internal audits.

Internal claim reviews are the single best way to assess your agency's compliance risks. Your claim reviews should evaluate the entire claim submission process from call intake and dispatch through payment and collections. Regularly reviewing a sample of your claims provides you with a snapshot of the process so you can uncover deficiencies. A claim review allows you to determine if sufficient information is being obtained through call intake, if crew documentation paints a complete and accurate picture of the patient's condition and treatment, if proper billing and coding decisions are made and if reasonable collection efforts are being pursued.

3. Resolve to supplement your internal audits with an annual external audit.

Periodic external audits are important to supplement your agency's internal audits. Ideally, a qualified outside ambulance claim auditor will look at a sample of your claims on at least an annual basis. Some agencies have an external audit completed two to four times per year. Sometimes the same errors made during claim submission can be missed during internal audits, so external claim audits are a necessary confidence check to the internal auditing process.

Make sure your external auditor has an appropriate credential like Certified Ambulance Coder or Certified Ambulance Compliance Officer. If your external auditor is a law firm, you have the added bonus of the protections of the attorney-client privilege.

4. Resolve to refund overpayments promptly.

Regular claim reviews are also a proactive compliance activity to identify overpayments. In 2016, a new set of regulations took effect that require providers to refund Medicare overpayments within 60 days of being identified. If overpayments are not refunded within this time, they become violations of the False Claims Act, which multiplies the financial consequences significantly. Make sure you have a process in place that begins with payment posting and involves regular reviews to identify any potential overpayments and then to promptly refund overpayments according to your Medicare Administrative Contractor's refund process.

5. Resolve to check the OIG Exclusions Database monthly.

The OIG has the authority to exclude individuals and entities from participating in federal health care programs. This means if someone is excluded, then they can't provide care that is paid for by federal health care programs, submit claims to federal health care programs or own or manage an entity that participates in federal health care programs.

In other words, someone who has been excluded probably can't be involved with your agency. Employing someone who is excluded can carry a hefty price tag. If, for example, a field provider is excluded, every transport paid by a federal health care program that individual participated in while excluded is an overpayment that must be refunded.

While it's not required, the OIG recommends checking the Exclusions Database on a monthly basis. All staff members should be checked prior to hire and monthly thereafter. Prior to engaging with any vendor, you should also check the entity against the database. If an individual or entity is excluded, you should not hire the person or engage the entity for services. If you discover that a current employee or vendor is excluded, you should immediately remove them from any activities associated with federal health care programs and contact your legal counsel.

If compliance has been ignored or overlooked at your agency, this is the year to make a change. Resolve to make compliance a priority every year to help your agency avoid costly mistakes.

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