UTMB HANDBOOK OF OPERATING PROCEDURES

Section 6 Compliance Subject 6.3. Coding and Billing Policy 6.3.2 Correction of Errors Related to Federal Healthcare Program Reimbursement

11/14/06-Originated - Reviewed w/ changes -Reviewed w/o changes Compliance - Author

Correction of Errors Related to Federal Healthcare Program Reimbursement

Definitions

Federal healthcare programs: Any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or part, by the United States Government (other than the health insurance program under Chapter 89 of Title 5 of the United Sates Code – the Federal Employees Health Benefit Program); or any state healthcare program, as defined in 42 U.S.C 1320a-7(h). Federal healthcare programs include, at a minimum, the following: • Medicare Program, Parts A & B (Title XVIII of the Social Security Act); (but not Medicare managed care plans) • Medicaid (Title XIX of the Social Security Act); (but not Medicaid managed care plans) • Federal Prison Hospitals (prisoners); • Indian Health Service; • OWCP (workers’ compensation for federal employees); • Public Health Service; • Railroad Retirement Board; • The Black Lung Program; • TRICARE/CHAMPUS/Department of Defense healthcare programs (Chapter 55 of Title 10, United States Code); and • Veterans Administration (VA).

Policy

UTMB will correct billing and collection errors for federal healthcare program reimbursement. UTMB shall make payments necessary to ensure the reimbursement it obtains from federal healthcare programs is accurate to the best of its ability. When UTMB becomes aware of an error it will take steps to remedy those errors as quickly as possible. Due to the nature of the reimbursement process, some corrections occur in real time or can be corrected by amending the submitted claim. In other circumstances, corrections are discovered as a result of a program or retrospective review or as a result of an investigation. Regardless of the method used to discover the error, UTMB will take steps to investigate and correct any billing or collection error as soon as it becomes aware of the issue.

Policy, continued

Anyone with knowledge of a potential error in reimbursement from a federal healthcare program must provide that information to their supervisor. The information provided should be as specific as possible including the type of problem, the date and place of occurrence and the dollar amount involved. If the employee does not feel that their supervisor has reported the information through the chain of command or the errors are not being corrected in a timely manner, the employee may contact the Institutional Compliance Officer (ICO) directly. See IHOP Policy 6.1.9 Reporting Suspected Wrongdoing (UTMB Open Door Policy), and IHOP Policy 6.1.5, Investigating Allegations of Non-Compliance.

Types of Reimbursement Errors

There are three potential types of errors. • Overpayment: An overpayment results, when UTMB has incorrectly submitted a claim to a federal healthcare program and is paid higher reimbursement for the services rendered when UTMB does not have documentation to support the claim. • Underpayment: An underpayment results, when UTMB has incorrectly submitted a claim to a federal healthcare program and is paid a lower reimbursement for the services rendered when UTMB has documentation to support a claim for reimbursement at a higher reimbursement rate. • Data Errors: Data errors occur when data on a claim is erroneous and the claim cannot be supported by any documentation. Data errors can be caused by bad reimbursement information in electronic systems or when a code is used but has been changed, modified, or no longer exists.

Routine Processing Errors

Routine processing errors should be corrected by either the individual who detects the error or the person who committed the error, and any necessary payments, or request for payment, should be made. Such errors should be reported to the supervisor. All errors must be appropriately processed and significant or substantial errors must be reported to the ICO. After consulting with the ICO, the department head and the ICO will determine the steps necessary to address potential significant

Routine Processing Errors, continued	or substantial errors. This will include but is not limited to investigating the particular situation, determining whether the matter is an isolated incident or part of a pattern of errors and developing any corrective actions required to remedy the situation.
Non-routine Processing Errors	Information regarding non-routine processing errors must be reported to the employee’s supervisor, Department Head and the ICO immediately. After consulting with the ICO, the department head and the ICO will determine the steps necessary to address potential errors. This will include but is not limited to investigating the particular situation, determining whether the matter is an isolated incident or part of a pattern of errors and developing any corrective actions required to remedy the situation.
Refund of Overpayments	UTMB will refund any money it does not rightfully deserve. However, due to the federal regulations governing the payback of money to federal healthcare programs, UTMB may determine it should communicate the error to the federal government. Due to the potential ramifications of communicating or self reporting overpayments, the ICO will be the responsible UTMB entity to manage this process. For more information on self reporting overpayments, see IHOP Policy 6.1.10, Self Reporting Overpayments to the Federal Government.
References	IHOP Policy 6.1.9, Reporting Suspected Wrongdoing (UTMB Open Door Policy) IHOP Policy 6.1.2 Non-Retaliation Policy. IHOP Policy 6.1.5, Investigating Allegations of Non-Compliance IHOP Policy 6.1.10, Self Reporting Overpayments to the Federal Government.