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Here are the compliance standards and procedures as outlined in a sample Medicare compliance plan prepared by Charlotte Kohler, RN, CPA, vice president of diversified services at Helix Health in Baltimore.
• False billings.
Any service and diagnosis used for billing must agree to the medical records in all items.
• Incomplete documentation/medical necessity.
Completion of medical records must be done timely and to the standard of this practice and the Healthcare Financing Administration’s. Medical necessity must be clearly indicated for services provided.
• Failure to provide necessary medical services.
Although certain managed care programs do not pay for testing, all care must be given to meet the normal standards of care.
• Misapplication of payments/lack of refunds.
Payments must be applied for the specific date and services. Credit balances must be returned based on the established criteria to determine to whom the refund is due. [Credit balances cannot be "offset" unless requested (in writing) by the patient.]
• Patient abuse.
Verbal and physical abuse of any patient will not be tolerated.
• Alteration/destruction of documents.
Any change in medical records or billing documents must be noted (with date and signature) without removal or change of original documents.
• Conflict of interest.
To the extent that any employer finds that under pressure a conflict of interest arises that diminishes his or her ability to conform to the Compliance Plan, it must be reported to the Compliance Officer immediately.