Effective: 04-29-24
Supersedes: 07-11-22
It is the policy of Brewster and EasCare Ambulance Services to conduct business with integrity. We make this commitment to our employees, customers, partner agencies, and the communities we serve. We are committed to ensuring that billing to Medicare, Medicaid, third-party private insurance, any other federal or state health care programs, and private payers is accurate and in full compliance with all applicable laws and regulations. All claims submitted for payment must have proper provider documentation to support them.
Overview of Billing Compliance Plan
The purpose of this Billing Compliance Plan (“Plan”) is to ensure that the employees of Brewster and EasCare Ambulance Service adhere to all appropriate Medicare, Medicaid, and all other healthcare laws, rules, regulations, and policies for submission of claims for ambulance or chair car services, mobile integrated health and overall ambulance operations.
This Compliance Plan was developed to assist team members in the prevention of improper or fraudulent billing practices. This plan promotes the use of best practices, and the prevention, early detection, and reporting of problems associated with the billing process before such can escalate to the point of governmental investigation and or litigation.
Key components of the Plan include processes to ensure accurate and proper resource allocation through emergency medical dispatch, documentation of pre-hospital care, documentation of transport mileage, appropriate coding and assignment of charges, and submittal of claims, combined with policies and procedures to detect, prevent, and report potential fraudulent billing practices.
The policies and procedures outlined in this Plan are applicable to all Brewster and EasCare Ambulance Service employees and any vendors who have a contractual relationship with the Company to provide billing and claims submission on behalf of Brewster or EasCare Ambulance Service. Employees or contractors who violate the policies and standards outlined in this Plan may be subject to appropriate disciplinary measures.
Federal Compliance Program Guidance
The laws governing the provision of ambulance services are constantly evolving. As such, the Billing Compliance Plan will be updated as necessary to ensure the company’s business and billing practices comply with applicable law and best practices. This compliance plan was developed in accordance with the U.S. Department of Health and Human Services, Office of Inspector General (“OIG”) recommendations as outlined in the OIG Compliance Program Guidance for Ambulance Suppliers.[1] The publication provides seven basic elements for an effective compliance program. These elements include:
1. Development of Compliance Policies and Procedures
2. Designation of a Compliance Officer
3. Education and Training Programs
4. Internal Monitoring and Reviews
5. Responding Appropriately to Detected Misconduct
6. Developing Open Lines of Communication
7. Enforcing Disciplinary Standards Through Well-PublicizedGuidelines
COMPLIANCE PLAN ELEMENTS
Development of Compliance Policies and Procedures
In addition to the Billing Compliance Plan, Brewster and EasCare Ambulance Service has developed written policies and procedures that reflect the Company’s standards of conduct, and commitment to compliance. These related policies and procedures require accuracy and honesty in all documentation and billing-related matters. The Company Policy and Procedure manual is updated as necessary and is available online.[2] Examples of billing-related SOPs include:
· ALS to BLS Referral
· Call Type
· Emergency Medical Dispatch Quality Assurance
· False Claim Reporting and Whistleblower Protections
· Interfacility Transport Guidelines
· Patient Assessment and Transport Guidelines
· Patient Care Report (PCR) Documentation
· Signature Requirements and Financial Responsibility
· Amendment of PCR
· Mileage Reporting
Designation of a Compliance Officer
The Billing Manager for the company will serve as the designated Compliance Officer. The Compliance Officer is responsible for oversight of the Plan and the associated standards, policies, and procedures. The Compliance Officer is assigned the duty and authorities associated with review of compliance related documents, information, educational and training material, and records maintenance, as related but not limited to, patient records, billing records, client arrangements, vendor agreements, etc. The Compliance Officer will be responsible for the following:
· Oversight of compliance-related policies and standards.
· Ensuring methods are in place to mitigate risk associated with fraud, abuse, and waste.
· Along with the Director of Policy and Regulatory Affairs, update of the Plan as necessary to reflect changes to laws, rules, and regulations governing the billing for and operation of ambulance transport services.
· Oversee, coordinate, assist, or develop and provide training activities and communications for the elements of the Plan.
· Conduct, assist with, or coordinate internal compliance reviews.
· Serve as investigator for all compliance related issues with the responsibility of providing reports to senior management as appropriate.
· Along with the Director of Education, ensuring that matters related to education, training, and communications in connection with the Compliance Program and this Compliance Plan are properly disseminated, understood, and followed; and
· Taking whatever actions are appropriate and necessary to ensure that Brewster and EasCare Ambulance Service conductsits billing activities in compliance with the applicable laws and regulations and sound business ethics.
Education and Training Programs
Brewster and EasCare Ambulance Service will effectively communicate its standards, policies and procedures to all employees and applicable persons, vendors, contractors, and others associated with the Company. The company will do so by providing training through traditional classroom education, or online training via MyBrewster. Employees will be informed of applicable federal laws, regulations, and standards of ethical conduct, and the consequences of violation of those rules or the Compliance Program.
A copy of this Compliance Plan is available to all new employees and is part of new employee training for all clinical and billing personnel.
Brewster and EasCare Ambulance Service will continue to use memorandums and electronic communications (as appropriate) to inform employees of changes in applicable federal laws and regulations. The Company will also distribute relevant fraud alerts and advisory bulletins issued by the Department of Health and Human Services - Office of the Inspector General.
Internal Monitoring and Reviews
Brewster and EasCare Ambulance Service will take all reasonable steps to maintain compliance through the monitoring and review of systems designed to prevent and detect fraudulent and noncompliant activity by employees, vendors, contracted agents, and others affiliated with the operations and billing of ambulance services performed by or on behalf of the Company.
This will include the development of processes to monitor and detect issues and prevent future issues. A random sample of claims for ambulance services will be performed periodically to ensure compliance with the guidance outlined in the Plan and as required by federal rules, regulations, and laws governing the practices of billing for ambulance services. Company employees and others can report issues of noncompliance or suspected illegal activity by others without fear of retribution.
Claims Billing and Submission
Brewster and EasCare Ambulance Service is committed to prompt, complete and accurate billing of all services. Billing will be for services provided only, and pursuant to all laws, terms and conditions, rules and regulations as specified by the government or other payer and in a manner consistent with known industry standards. No falsification of documentation or misleading entries will be made or submitted on any bills or claim forms. Any false statement on any bill shall subject the employee to disciplinary action by Brewster and EasCare Ambulance Service, including possible termination of employment.
Brewster and EasCare Ambulance Service billing department employees should become familiar with the Medicare and Medicaid policies and procedures regarding billing and reimbursement as set forth by the United States Department of Health and Human Services (Medicare Reimbursement) and state law regarding the general policies and procedures necessary to obtain reimbursement under Medicare and Medicaid.
Claims will not be knowingly submitted for services that were not provided, nor for a level of service that exceeds the level of service actually provided.
All forms of documentation, paper or electronic, related to patient assessment, treatment, and/or transport, including dispatch records, patient care reports, physician certification statements, medical and nursing notes, and other documentation used as a basis for a claim submission will be appropriately organized and maintained as required.
Levels of service, patient condition and procedures reported on claims for reimbursement are based on the patient care report as documented by the caregiver at the time of service and other legitimate supporting documentation.
Medical Necessity is an area of very significant concern to Medicare, and all Brewster and EasCare Ambulance Service employees and contractors must attempt at all times to ensure that ambulance services are provided and billed only when medical necessity is present for the trip. Medical Necessity for ambulance transportation is established when the patient's condition, at the time of transport, is such that use of any other method of transportation is contraindicated, whether or not other transportation is actually available. Medical Necessity is presumed to have been met if the patient, at the time of the transport:
· Was transported in an emergency situation, i.e., as a result of an accident, injury, or acute illness
· Needed to be restrained, was unconscious, or in shock
· Required oxygen or other emergency treatment on the way to the destination
· Had to remain immobile because of a fracture that had not been set or the possibility of afracture
· Sustained an acute stroke or myocardial infarction
· Was experiencing severe hemorrhage
· Was bed confined before and after the ambulance trip and going for the purpose of a stated medically necessary treatment (bed confinement alone does not necessitate ambulance transport) or
· The patient could be moved only by stretcher (for the purpose of receipt of a medically necessary treatment)
Regular Claims Audits
To ensure compliance with the rules and regulations directing billing of ambulance services and to detect potential errors in coding, documentation, and medical appropriateness the Compliance Officer will regularly request an audit of randomly selected claims. Samples of pre- and/or post-submission claims are audited to verify accuracy, check for any possible errors, and ensure that all Medicare coverage criteria are met.
On a monthly basis, at least thirty (30) claims will be selected at random and reviewed for accuracy (“self-audit”). Upon review of claims that have not been billed, a determination will be made as to whether each claim can be submitted for payment as prepared, or whether corrections or additional documentation is required.
Upon review of claims that have been paid, a determination will be made as to whether the claim was appropriately billed and paid, and whether an overpayment or underpayment exists. In each case, compliance with all Medicare coverage criteria should be evaluated. A denied or “downcoded” claim will be further reviewed and a decision made as to whether the claim should be appealed.
Information for each claim shall be reviewed, including a review of the CMS 1500 claim form (or its electronic equivalent), the electronic remittance advice, the PCR, the PCS (if applicable), the CAD notes (or other dispatch instructions or information) if available, and all other available and relevant information. The self-audit process shall ensure that claims for ambulance transports of Medicare beneficiaries meet the requirements for a “covered transport” in accordance with guidance from CMS.
In the event of the discovery of repetitious compliance errors, significant overpayments, or apparent violations of the law during these claims audits the Compliance Officer will inform the Company President and seek the advice of the counsel. Legal counsel will advise as matters of attorney/client privilege, disclosure, and as to whether Brewster and EasCare Ambulance Service is required to report the violations and/or make restitution for errors and overpayments. Brewster and EasCare Ambulance Service’s legal counsel may advise or recommend procedures for notification of the MAC or as to the utilization of the OIG’s Provider Self-Disclosure Protocol.
Risk Assessment
On a routine basis, we will perform a risk assessment, which will include a review of potential risk areas identified by the OIG as well as any other potential risks identified by the Compliance Officer.
1. At least annually, the Compliance Program Officer will conduct a risk assessment of Brewster’s billing policies. The risk assessment may be conducted with the assistance of legal counsel or consultants who have experience with compliance risks involving ambulance services.
2. The risk assessment will include an evaluation of the risk areas identified by the OIG in Compliance Program Guidance as well as other OIG publications and any other risk areas impacting Brewster as identified by the Compliance Officer. The Compliance Officer may consider laws, regulations, policies and conduct as well as complaints or concerns reported by personnel, prior audits or lawsuits, and external audits and reviews among other factors when identifying areas of potential risk.
3. As part of the risk assessment, the Compliance Officer may evaluate Brewster’s policies and procedures, employee training, employee knowledge, the claims submission process, documentation practices, management structure and commitment to compliance, contractual arrangements, and technology relied upon in the claims submission process to identify areas where Brewster may be exposed to compliance risk.
4. After identifying potential risks, the Compliance Officer will evaluate all of the identified potential risks along with the systems and controls Brewster currently has in place to combat those risks. Compliance program efforts will be focused on the areas with greatest potential risk to Brewster and those areas where Brewster needs to improve systems and controls.
5. The Compliance Officer may choose to implement a Corrective Action Plan to address some of the identified risks to ensure risks are properly mitigated.
Overpayments
A Medicare or Medicaid overpayment is defined as funds paid in excess of the amount that would be properly payable for a service provided under Medicare or Medicaid statutes and regulations. Medicare overpayments may be the result of:
· Duplicate billing for the same claim
· Billing for service levels above what was necessary or provided
· Billing for services that were not medically necessary
· Payments made to the incorrect payee
The Patient Protection and Affordable Care Act requires that providers report and refund Medicare overpayments within 60 days of the date that the overpayment is “identified”. Identified for this purpose is classified as the time when a person has actual knowledge of the overpayment or acts in “reckless disregard or deliberate ignorance” of the existence of an overpayment. Failure to process refunds in this manner could be a violation of the False Claims Act and could result in civil monetary or other penalties. While this rule does not address Medicaid payments, Brewster and EasCare Ambulance Service will process refunds in the same manner as those identified for Medicare services.
If a payer identifies an overpayment and issues a demand notice, billing personnel will review the request to determine if an overpayment does indeed exist. Brewster will contest the overpayment demand or initiate a refund promptly in accordance with the timeframe established in the letter or with typical payer practices.
Employee Responsibility
In the event an employee has any reason to suspect improper billing practices, that person shall immediately report the practices to the Compliance Officer for review. Failure to act, when an employee has knowledge that someone is engaged in false billing practices shall also be considered a breach of that staff member's responsibilities and may subject them to disciplinary action by Brewster and EasCare Ambulance Service as well.
Responding Appropriately to Detected Misconduct
The intention of the Plan is to detect and prevent noncompliant activity that results in violation of governing laws, established reimbursement regulations, and policies outlined and expressed by the federal government and/or payers of ambulance services.
Brewster and EasCare Ambulance Service commits to taking all reasonable steps to promptly respond appropriately to all detected and reported compliance offenses, taking corrective action against the offense/offender(s), and providing for prevention of similar offenses in the future. Modifications to the Plan will be made as necessary upon the detection and reporting of any offense in order to strengthen the Plan. The Compliance Officer, and legal counsel in circumstances serious enough in nature to require such, will be involved in the response to identified compliance misconduct.
Government Investigations
Brewster and EasCare Ambulance Service’s policy is to cooperate with reasonable demands of governmental agencies and investigations while also ensuring the protection of the Company’s legal rights.
Information disclosed without proper authorization jeopardizes the rights of our patients. We also do not want to hinder in any way a legitimate government investigation. If a federal or state official requests information from a Brewster staff member, the staff member should direct the individual the Compliance Officer.
In the event of an onsite governmental agent visit, management should be contacted immediately. In turn, the supervisor/manager will immediately contact the Compliance Officer. The Compliance Officer will notify Brewster and EasCare Ambulance Service legal counsel for advice as to how to proceed based upon the situation and nature of the visit.
Whenever there is any indication that a government investigation may be underway, under no circumstances will any records or documents that could have a bearing on that investigation be destroyed or altered in any way.
Developing and Maintaining Open Lines of Communication
Brewster and EasCare Ambulance Service has developed and will maintain a process for receipt and process of compliance related concerns and complaints. This process will ensure that open and effective lines of communication are established and preserved between the Compliance Officer and all employees.
Mechanisms for Violations Reporting
Brewster and EasCare Ambulance Service takes issues regarding potential false claims, fraud and abuse seriously. Employees are required to report violations of this Compliance Plan, Standards of Conduct, or suspected incidents of fraud and abuse. The Company encourages employees with any questions or concerns regarding billing issues to report such concerns to their immediate supervisor for clarification or resolution.
Alternatively, in accordance with the company’s “open door” policy, concerns, suggestions and questions may be brought to the attention of management or ownership at any time. Concerns may also be brought to the Company’s designated Compliance Officer by telephone at 781-808-9038 or email at COMPLIANCE@BrewsterAmbulance.com.
All reports will be treated confidentially to the extent reasonably possible. Brewster / EasCare will not take any adverse action against an individual who notifies the Company or government agency in good faith about potential violations, or participates in the investigation of an alleged violation. Brewster and EasCare Ambulance Service commits to providing all the protections set forth in the applicable laws regarding anti-retaliation for the reporting of potential law violations. However, if an employee knowingly provides a false report in order to injure or cover for someone else or to cover for themselves, Brewster and EasCare Ambulance Service will take appropriate disciplinary action.
Enforcement of Disciplinary Standards
Brewster and EasCare Ambulance Service has developed standards, policies and procedures to respond to infractions and violations of compliance, and provide disciplinary measures in a fair and consistent manner where needed.
Brewster and EasCare Ambulance Service maintains a "zero tolerance" policy towards any illegal conduct. Any staff member engaging in a violation of any laws or regulations may be terminated from employment. When appropriate, discipline may also be enforced against employees for failing to detect or report suspected wrongdoing.
Billing Related Policies and Procedures
Repetitive Ambulance Transports
A repetitive ambulance transport is defined as a medically necessary ambulance transport that is furnished three or more times during a ten-day period or at least once per week for at least three weeks. All documentation for repetitive transports must be complete in full in order to bill.
Multiple Payers- Coordination of Benefits
Billers should make every effort to determine whether Medicare, Medicaid, or other federal health care programs should be billed as the primary or as the secondary insurer. Claims for payment should not be submitted to more than one payer, except for purposes of coordinating benefits.
Fractional Mileage Billing
Ambulance providers must report mileage units rounded up to the nearest tenth of a mile for claims with mileage totaling less than 100 covered miles. Providers must submit fractional mileage using a decimal in the appropriate place (e.g., 99.9).
For trips totaling 100 miles and greater, suppliers shall continue to report mileage rounded up to the nearest whole number mile (e.g., 999). For mileage totaling less than 1 mile, providers and suppliers must include a “0” prior to the decimal point (e.g., 0.9).
Confidentiality
Brewster and EasCare Ambulance is dedicated to protecting its patients’ personal privacy and confidentiality of information consistent with Brewster’s mission, applicable laws (including HIPAA and HITECH) and quality standards. No member of the organization should use confidential or proprietary information for his or her own personal gain or for the benefit of another person or entity.
Information concerning a patient is confidential. Brewster personnel should not obtain or divulge details of a patient’s condition without a specific professional reason, except as required by law. Violations will be handled in accordance with Brewster disciplinary policies, and/or our HIPAA policies, where applicable.
Access to a patient’s billing record shall be treated with utmost respect and confidentiality. Access to both electronic medical records should be limited to only those employees for whom the information is necessary for the completion of job duties.
Gifts to Government Representatives
Staff members should not provide gifts or pay for meals, refreshments, travel, or lodging expenses for government or public agency representatives with the intent to influence an official action or decision in an illegal, unethical or unlawful manner.
Account Adjustments, Financial Hardship and Bankruptcy
Billing personnel should not offer discounts, professional courtesies, or waiver of co-payments or deductible unless approved by a billing supervisor.
Brewster Ambulance billing personnel will make good faith effort to collect all patient co-payments, deductibles and other amounts due by the patient or responsible party.
1. Account Adjustments:
a. Charges are not to be entirely written off without the approval of the billing department manager.
b. Billing Department team leads have the authority to authorize a courtesy reduction on a patient’s outstanding balance of up to 20% as long as the patient (or their representative) reaches out to us with a concern on being able to pay.
c. The account can be reduced by a maximum of 30% if approval is granted by the billing department manager.
d. Neither of these percentages can be applied if it would place the total collectable charges for the account below MCR allowable rates.
2. Financial Hardship: Departure from our standard attempts to collect co-payments or deductible amounts or payment in full from the patient may occur when the patient or patient representative advises us that the patient is suffering a financial hardship and is unable to make payment:
a. We will ensure that insurance benefits have been maximized and offer a payment installment plan.
b. If the patient claims financial hardship and inability to satisfy a payment installment plan, we will conduct a Financial Hardship Assessment. A patient is eligible to be declared a “Financial Hardship” case and may be eligible for a waiver or discounted services if the patient’s household income is at or below the income levels in the annual poverty guidelines published by United States Department of Health and Human Services.[3]
c. A patient’s financial and insurance status is subject to change. The fact that a patient qualifies for financial hardship treatment at one time does not mean that the patient will qualify for financial hardship treatment in the future.
3. Bankruptcy: employees will adhere to the following guidelines concerning bankruptcy:
a. When a notice of bankruptcy filing is received, all pertinent information should be noted on the patient account.
b. The patient should not receive calls or letters regarding outstanding charges while a bankruptcy is pending.
c. If a Discharge is received, any balances incurred prior to the bankruptcy filing date should be written off and the notice attached to the patient account.
d. If a Dismissal is received, the notice should be attached to the patient account, the account should be noted and the appropriate billing account status should be restored.
Discounts or Waivers for Employees
Active employees and their immediate family members who receive emergency ambulance transport by Brewster Ambulance Service or EasCare Ambulance are eligible for discounts or waivers of outstanding balances.
Brewster Ambulance Service will submit an invoice for services to the health insurance carrier of the patient being transported in accordance with our usual billing practices. Any funds received for services will be applied to the balance of the invoice and the payment will be considered paid in full, and the account closed.
Aside from the active Brewster or EasCare employee, for the purposes of this policy, “immediate family member” is defined as an employee’s spouse / partner, dependent children, mother and father, and mother-in-law and father-in-law of the employee.
Employees requesting a discount or waiver should forward the request to their regional manager for review as soon after the transport as possible. Once approved, the waiver request will be forwarded to the Billing Department.
Waiver of Bill: Unusual Circumstances
The False Claims Act and Anti-Kickback Statutes prohibit the routine waiving of bills or co-pays designed to induce additional business. However, there may be situations in which a waiver or discount is not only permissible, it is the right thing to do. For example, the waiving of a bill may be appropriate in isolated situations in which we contributed to the need for the transportation in the first place. Requests to waive an ambulance bill completely may be forwarded by a Regional Manager or Director to the Chief Operating Officer or Chief Executive Officer for review and approval. Such a request shall be made as soon after the transport as possible.
Returned Mail
When an account statement or other patient correspondence is returned by the post office an attempt should be made to contact the patient by phone.
If the attempt is successful, the patient account should be corrected and the correspondence should be re-mailed. If the billing specialist is unable to resolve the address problem the following processes will be applied.
1. The old address should be documented in the notes to alert the Billing Specialist.
2. The Bill schedule should be changed to a Mail Return status.
3. The Billing Specialist should seek an updated address or other outside sources. If they are unable to resolve the problem, the Billing Specialist must make a determination regarding the handling of the debt.
Bad Debt and Collections
Billing staff will routinely produce aging reports to identify uncollected balances and/or bad debt. Bad debt balances will be reported to the Vice President of Business Development for determination about future actions.
The following classifications of Bad Debt and Collections will determine which process will be applied:
1. Bad Debt: Remaining balance due on an account after an insurer and/or individual has been billed with no response in payment.
2. Internal Collections: At least two formal letters are sent, and two phone call are made to the responsible party when an account remains past due. If those actions do not produce a response, further action will be taken according to conditions set forth by the billing manager.
3. External Collections: After all resources have been exhausted, remaining account balances may be turned over to an outside collection agency.
4. Standard Adjustments: Amounts added or subtracted to the account balance to reflect charge corrections, allowable amounts or payment arrangements.
5. Write-Off: Amount subtracted from an account after the debt has either been forgiven by the company or transferred to external collections.
Billing staff will follow these guidelines when handling bad-debt accounts:
1. Routine monthly aging reports are run to identify and make efforts to collect outstanding balances.
2. Accounts with uncollected balances greater than 30 days will be submitted to the Vice President of Business Development for recommended actions. A spreadsheet will be maintained of all aging accounts which will include payer name, amount delinquent by age (1-30 days, 31-60 days, 61-90 days, 91 days and older).
3. Each month the spreadsheet will be generated and updated with the progression of the actions recommended. Actions which can be recommended include the following:
Option 0 – BD team action and meetings with the account representative
Option 1 – Brewster Ambulance Service Demand Letter is submitted
Option 2 – Legal Demand Letter is submitted
Option 3 – External Collections Agency submission
Option 4 – Account Write-off
The Vice President of Business Development will submit the spreadsheet with recommendations to the Chief Operating Officer by the 10th day of each month. After review by the Chief Operating Officer, the document will be submitted for final approval to the CEO and Vice President of Brewster Ambulance Service.
4. All notes, attempted outreach, and outcomes are to be documented on the patient account.
OIG Excluded Individuals
All personnel and contractors are subject to background screening. Brewster will not employ or do business with individuals or entities who have been convicted of health care fraud or listed by a federal agency as excluded, debarred or otherwise ineligible to participate in federal health care programs.
1. We will utilize the Office of Inspector General’s List of Excluded Individuals/Entities (“LEIE”) to determine if an individual or entity has been excluded from participation in federal health care programs. For individuals, both current and maiden names or any other prior legal names shall be checked.
2. We shall check the LEIE on a monthly basis to determine whether any of our personnel or entities with which we contract are excluded from a federal health care program.
3. We will require our contractors to check the LEIE on a monthly basis to determine whether any of their personnel have been excluded from a federal health care program and to alert us promptly if an excluded individual is involved in any way with providing services (directly or indirectly) for us under the contract.
4. We do not allow an individual who is excluded from a federal health care program to work for us in any capacity that directly or indirectly involves the provision of service payable by a federal health care program. This includes, without limitation, field personnel, billers, coders, and administrative and management personnel.
5. We will take disciplinary action against any of our personnel who fail to immediately notify us of exclusion from a federal health care program, debarment by a federal agency, a criminal conviction or a civil monetary penalty assessed against the individual for conduct involving a federal health care program.