UTMB HANDBOOK OF OPERATING PROCEDURES

Section 6 Compliance Policies Subject 6.3 Coding and Billing Policy 6.3.1 Billing Compliance Monitoring

01/25/06 - Originated - Reviewed w/ changes - Reviewed w/o changes Compliance Office - Author

Billing Compliance Monitoring

Audience

The information in this document applies to all UTMB faculty, staff, students, volunteers, and contractors.

Policy	All claims for reimbursement made by or on behalf of UTMB hospitals or UTMB clinical providers shall adhere to applicable laws and regulations governing the reimbursement of medical services. UTMB shall collect only those amounts to which UTMB is entitled and refund amounts billed and/or collected in error. The UTMB Office of Institutional Compliance (OIC) is responsible for monitoring UTMB’s billing and reimbursement efforts to ensure UTMB is in compliance with federal and state laws and regulations regarding the billing and reimbursement of federal and state monies.
Billing Compliance	The OIC is responsible for developing and operating UTMB billing compliance activities. This includes providing expert advice and opinion on all aspects of UTMB coding and billing for all aspects of the UTMB clinical operation. As part of this activity, OIC provide specific training and formal opinion on issues requiring clarification.
Monitoring Obligations	Under the supervision of the OIC, a sample of medical records and corresponding claims for each department and division is periodically reviewed for compliance. UTMB plans to review each department at least annually, but the OIC may require more frequent reviews. Reviews may perform individual physician, or various issue specific reviews on an as needed basis. Reviews may include on-site visits; interviews with personnel involved in administration, operations, billing, reporting, and other related activities; review of documentation and other written materials; and trend analysis. The results of such reviews are discussed with the department administration and to the Institutional Compliance Committee (ICC). In addition, UTMB's Director of Internal Audit, as appropriate, may perform independent reviews and reports the results of such reviews to the Institutional Compliance Officer (ICO). Moreover, the OIC may engage an external billing expert or auditor to review records for a particular department or a cross-section of departments. If any of these reviews identify instances of possible non-compliance, the OIC reports that information to appropriate management and the ICC. The OIC reviews the findings to determine whether there appears to have been any activity inconsistent with UTMB billing and coding policies.

Monitoring Obligations (cont’d)

The UTMB ICO has the authority to suspend billing activity of any department, as the situation warrants, until the department is able to demonstrate ability to maintain compliance The OIC undertakes an analysis to determine any overpayment amount(s). All overpayments identified in any billing monitoring review will be refunded to the appropriate payer. The OIC may develop and employ various monitoring techniques custom tailored to address identified issues.

Determinations of the Office of Institutional Compliance

Routinely, the Office of Institutional Compliance may issue a policy, interpretation, opinion, or determination regarding various laws, regulations, or guidance or interpretation of rules. Examples of determinations the OIC may make include, but are not limited to: • use of a specific Current Physician Terminology (CPT) or diagnosis code • Emergency Medical Treatment and Active Labor Act (EMTALA) • teaching physician guidelines; and/or • Health Insurance Portability and Accountability Act (HIPAA) issues. UTMB will operate under the presumption that the Office of Institutional Compliance determination is definitive and correct. However, a department or entity may present an appeal to a determination made by the Office of Institutional Compliance. See IHOP Policy 6.1.3 Appeal of a Determination by the Office of Institutional Compliance.