Compliance Program Initiatives

Compliance Program Elements

The UCSF Clinical Enterprise Compliance Program provides a variety of programs and services to the UCSF clinical community. We model our efforts on the industry standards for an Effective Compliance Program.

External Review Coordination

Providers/Departments should be on the lookout for any correspondence from, for example, CMS, Medicaid, Medi-Cal, or Contractors working on behalf of any Government payor entity, Palmetto (our Medicare Fiscal Intermediary), or private insurance companies sent directly to the billing provider, related to a request for medical records to substantiate billing claims under review. UCSF Providers are directed to forward audit requests to their Department Manager for reporting to the Compliance Program.

The Compliance Program will provide coordination and processing of the response as well as perform internal review. Additionally, Compliance will appeal any request for repayment, as supported by our internal review. The Compliance Program will provide overall guidance for the response, including: review of billing processes and documentation, drafting of cover letters and other appropriate correspondence, facilitatation of timeline extensions, as needed; and communication with the Medicare office for any clarification needed.

Recovery Audit Contractors (RAC)

Comprehensive Error Rate Testing (CERT)

Payment Error Rate Measurement (PERM)

Partnership in Compliance SharePoint Sites

We have created SharePointTM sites to provide department managers and their designees various tools, resources and communication regarding compliance projects. Please contact us to discuss your department's site.

Consultations

The Compliance Office provides consultative services to requesting departments for clarification of coding, documentation and billing requirements for areas of specific concern. Consultation requests may require extensive research utilizing the Federal Register, Code of Federal Regulations, California Code of Regulations, Centers for Medicare and Medicaid Services, Medi-Cal Manuals, and other information sources that may assist in the analysis for final determination.

Reviews & Monitoring

Routine Monitoring: The Compliance Office is responsible for conducting routine monitoring of health care claims practices throughout the health care enterprise. The Compliance Officer will determine the specific methodology for pursuing routine monitoring. When the magnitude of any identified overpayment (actual or potential) is significant, or where the facts suggest that the noncompliance may be widespread, the Compliance Officer shall initiate an Expanded Review. An Expanded Review is required when the results of routine monitoring identify high-risk billing errors, such as the existence of any of the following conditions:

No documentation for services billed;
Co-signed notes that do not support teaching physician presence / involvement; or
Other potential systemic issues, such as incorrect assignment of codes in charge documents, unbundling, and repeated instances of the same billing or coding error.

When routine monitoring demonstrates that an overpayment has occurred, a refund shall be made to the appropriate payor/contractor with reasonable promptness or as required by law. (See PPACA, Section 6402, p. 658).

Expanded Review: An expanded review shall be conducted either following routine monitoring as outlined above, or in response to a complaint or other specific information indicating potential noncompliance. The Compliance Officer shall exercise professional judgment as to the scope of the expanded review (e.g., number of charts/claims to be reviewed, time period to be examined).

If the expanded review indicates that the noncompliance is widespread (is equal to or exceeds 10%), the Compliance Officer may conduct further investigation unless, after consultation with the Compliance Committee and the Office of General Counsel, the Compliance Officer determines that an investigation is not warranted under the circumstances. When the Expanded Review indicates that the noncompliance is not widespread (is less than 10%), the Compliance Officer, exercising professional judgment, still may conduct an Investigation.

Investigation: Where the circumstances require an Investigation, or where the Compliance Officer, in his or her discretion, determines that an Investigation is warranted, the Investigation shall be undertaken with reasonable promptness.

The Compliance Officer shall develop an Investigation plan, which shall address such matters as the population to be examined, sampling methodology, payor(s) and codes at issue.

OIG/GSA Sanctions Monitoring

Campus and Medical Center Human Resources, and Campus and Medical Center Materiel Management are responsible for assuring that policies and procedures are in place to screen all employees and vendors against the exclusion/debarment lists of the HHS Office of the Inspector General (OIG) and the General Services Administration (GSA). In addition, newly hired employees or newly contracted vendors will be screened either before first providing services or soon after.

When an employee or vendor is identified as excluded, the Medical Enterprise shall refund any payments made under Medicare (Title XVIII), Medicaid (Title XIX), Maternal and Child Health Services Block Grant (Title V), Block Grants to States for Social Services (Title XX) and State Children's Health Insurance (Title XXI) programs during the period of exclusion for any items or services (including administrative and management services) furnished, ordered, or prescribed by the excluded individual or entity.

The Campus and Medical Center will report, on a monthly basis, the results of their exclusion screening program to the Compliance Officer. Annually, the Compliance Officer will review the results of the exclusion screening program for compliance with Federal requirements.