Healthcare Law and ICD-10-CM/PCS Codes

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Questions and Answers

What is a crucial aspect of disciplinary actions in a compliance program?

Immediate termination for noncompliance

Fair, equitable, and consistent discipline (correct)

No discipline for first-time offenses

Unfair and inconsistent discipline

What is the primary purpose of settling allegations of violations?

To focus on DRG creep risk areas

To resolve legal issues while avoiding protracted litigation (correct)

To agree to corrective actions

To avoid financial settlements

What is the purpose of the initial meeting between the employee's manager and the employee in progressive discipline?

To issue a written warning

To discuss the problem and secure the employee's understanding and commitment to correcting behavior (correct)

To terminate the employee immediately

To suspend the employee without pay

What happens if an employee fails to report suspected noncompliance?

They will be equally deserving of discipline as the actual misconduct Signup and view all the answers

What is the main function of ICD-10-CM/PCS codes?

To classify diseases, symptoms, and abnormal findings Signup and view all the answers

Who is responsible for monitoring consistency in discipline for fairness and severity?

Compliance Signup and view all the answers

What is the result of upcoding practices?

A higher reimbursement rate Signup and view all the answers

What is the focus of OIG's enforcement efforts?

Upcoding practices Signup and view all the answers

What is the purpose of a written warning in progressive discipline?

To emphasize the seriousness of the situation and stress the urgency of modifying behavior Signup and view all the answers

What is the purpose of DRGs or diagnosis related groups?

To form the basis for government payment Signup and view all the answers

What is the consequence of intentional or reckless noncompliance?

Significant sanctions Signup and view all the answers

What is the result of DRG creep?

A higher payment rate Signup and view all the answers

What is the role of HR in the disciplinary process?

To work with management in imposing discipline Signup and view all the answers

What is the ultimate goal of progressive discipline?

To correct employee behavior and prevent future noncompliance Signup and view all the answers

What is essential for the Board to have in terms of compliance?

An active role Signup and view all the answers

Why is management buy-in critical in compliance?

It influences and makes a compliance program work Signup and view all the answers

What is key in the healthcare setting for compliance?

Physician support Signup and view all the answers

What should be emphasized when communicating with physicians about compliance?

Both business and clinical aspects Signup and view all the answers

What is everyone's responsibility in an organization?

Compliance is everyone's responsibility Signup and view all the answers

What is the first step in compliance?

Education Signup and view all the answers

What is necessary to properly run a compliance program?

Financial resources Signup and view all the answers

What influences the government's interpretation of an organization's commitment to good corporate citizenship?

The amount of financial resources invested Signup and view all the answers

What is the importance of having an acknowledgement or attestation form in a code of conduct?

To ensure compliance with regulatory requirements Signup and view all the answers

What is the most important characteristic of a Compliance Officer?

Trust and respect within the organization Signup and view all the answers

What is the primary purpose of conducting a risk assessment?

To identify risks and develop plans to address them Signup and view all the answers

What is the benefit of reviewing the risk list periodically?

To identify new risks and assess mitigation plans Signup and view all the answers

What should be the primary focus of the compliance department once it is in place?

Conducting a risk assessment Signup and view all the answers

What is the purpose of developing an annual compliance report?

To get word out and build support for the compliance department Signup and view all the answers

Why is it important to have good people skills in the compliance department?

To build trust and effective relationships with employees Signup and view all the answers

What should be the outcome of the risk assessment process?

A prioritized list of risks with plans for action Signup and view all the answers

What information must be included in the notice to the individual about a breach?

A description of what happened, including the date of breach and discovery, and types of information involved Signup and view all the answers

What is the purpose of the four tiers of penalties under HITECH?

To assess the amount of Civil Monetary Penalties for violations Signup and view all the answers

What is the minimum penalty per violation under HITECH?

$100 Signup and view all the answers

What is the cap for identical violations under HITECH?

$1,500,000 Signup and view all the answers

What type of violations would be subject to a penalty of $10,000 up to $50,000 per violation?

Violations due to willful neglect, but corrected by CE Signup and view all the answers

What must be included in the notice to the individual in addition to the description of what happened?

Steps individuals can take to protect themselves and contact information Signup and view all the answers

Why has enforcement increased under HITECH?

Due to an increase in Civil Monetary Penalties for violations Signup and view all the answers

What is the purpose of the contact information in the notice to the individual?

To allow individuals to ask questions or learn additional information Signup and view all the answers

Study Notes

Mitigation and Settlements

Entities may settle allegations of violations by agreeing to corrective actions, financial settlements, or other terms to resolve legal issues and avoid litigation.

ICD-10-CM/PCS

ICD-10-CM/PCS is a classification system with 17,000 numeric clinical codes for diseases, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease.
Codes are organized into DRGs (diagnosis related groups), which form the basis for government payment.

Upcoding

Upcoding is the practice of using a billing code that provides a higher reimbursement rate than the code that accurately reflects the service furnished.
Upcoding has been a major focus of OIG's enforcement efforts, and HIPAA added an additional civil monetary penalty to the OIG's sanction authorities for upcoding violations.

DRG Creep

DRG Creep is the practice of billing using a DRG code that provides a higher payment rate than the DRG code that accurately reflects the service provided.

Enforcement and Discipline

OIG believes that the compliance program should include a written policy statement setting forth the degree of disciplinary actions that may be imposed.
Discipline will be administered for non-compliant activity, and employees have an obligation to report suspected noncompliance.

Failure to Report

Failure to report an offense is a serious act of noncompliance and equally deserving of discipline as the actual misconduct.

Progressive Discipline

Progressive discipline is a multi-step process that includes:
- Meeting with the employee to discuss the problem and secure a commitment to correcting behavior
- Written warning that emphasizes the seriousness of the situation and stresses the urgency of modified behavior
- Suspension without pay or a probationary period where if the behavior continues, the employee will face termination

Board Involvement

It is in the best interest of the organization for the Board to have an active rather than a passive role in compliance.

Management Support

Management buy-in is critical in influencing and making a compliance program work.
Compliance officers should work with management and include them in investigations.
Managers must also lead by example, as actions speak louder than words.

Physician Support

Physician support is key in the healthcare setting.
Ways to communicate compliance with physicians include:
- Discussing both business and clinical aspects of an issue
- Emphasizing clinical and fiscal improvements
- Building trust through involvement
- Involving physicians early in the process
- Providing data
- Working one-on-one with them

Staff Support

It isn't a crime to make a mistake; it is a crime to not do anything about that mistake once it is detected.
Staff must know that compliance is everyone's responsibility, not just the Compliance Department.

Financial Support

Management all the way up to the Board must be willing to financially invest in Compliance.

Compliance Budget

You can't run a compliance program properly without the financial resources.
The amount of $$ you need will depend on the size and scope of compliance responsibilities.

Staffing

Organization size, setting, and culture will influence how the compliance department is staffed.
In a small organization, the Compliance Officer role may not be full-time.
Administrative support may be necessary.

Conduct Risk Assessment

After the compliance department is in place, the first step is to launch an effective compliance program by conducting a risk assessment.
The purpose is to identify risks in the organization, analyze those risks against controls in place, prioritize those risks, and develop plans for action to address the risks prioritized.

Develop Mission and Goals

Once staff is in place, it must function as a team towards a common goal.
Develop a compliance department mission statement.
Develop annual team goals that are achievable and measurable.
An annual compliance report should be developed to get the word out and build support for the compliance department.

Notice to Individuals

The notice to the individual must include:
- A description of what happened, including date of breach and date of discovery
- Description of the types of information involved in the breach
- Steps individuals can take to protect themselves from harm
- Descriptions of what the CE is doing to investigate the breach, to mitigate harm to the individuals and protect against further breaches
- Contact information for the individuals to ask questions or learn additional information

Enforcement Penalties

Initially, enforcement was complaint-driven, but enforcement has increased, as well as an increase in Civil Monetary Penalties for violations.
HITECH has penalty tiers, with a minimum of $100 per violation up to $50,000 per violation.
Tiers are based on accidental vs intentional, as well as actions taken by CE to correct and prevent future breaches.
Four Tiers:
- Violations that were inadvertent and the CE would have taken different action if they were aware. $100 up to $50,000 per violation
- Violations due to reasonable cause but not willful neglect. $1,000 up to $50,000 per violation
- Violations due to willful neglect, but problem has been corrected by CE. $10,000 up to $50,000 per violation
- Violations due to willful neglect and problem has not been corrected. Starts at $50,000

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Description

This quiz covers legal aspects of healthcare, including mitigation and settlements, as well as the International Classification of Diseases, 10th Edition, Clinical Modifications (ICD-10-CM/PCS) coding system.