STANDARDS OF CONDUCT
These Standards of Conduct set forth the basic principles that guide PPCWNY decisions and actions. All Affected Individuals are expected to familiarize themselves with and rely on these standards in carrying out their duties.
The Standards of Conduct are not intended to address every potential compliance issue that may arise over the course of PPCWNY’s business. Employees are required to review and carry out their duties in accordance with the policies applicable to their job functions. The Standards are set forth below.
I. Billing for Services
PPCWNY and its staff provide a variety of services to patients and the community. PPCWNY is paid for its services in different ways. PPCWNY obtains reimbursement from government programs such as Medicaid and Medicare for health care services provided to its patients. PPCWNY also receives payment from federal and state grant programs for the provision of family planning items and services. The submission of accurate bills to government payers are one of the PPCWNY’s key legal obligations.
Because of PPCWNY’s mission, some of these services are provided at no charge, or at reduced rates. In most cases, claims and billing statements are provided to the patient or a third-party payer responsible for payment. It is imperative that - regardless of who pays PPCWNY and on what terms – PPCWNY’s bills and supporting documentation accurately reflect: the services actually provided, who performed the service, as well as all other pertinent data relating to the patient that is required by the particular third-party payer.
It is, of course, fundamental that no one at or acting on behalf of PPCWNY would intentionally falsify a claim. Such conduct is a crime; it is never in the interest of PPCWNY and will result in severe sanctions including, but not limited to, dismissal. However, negligently prepared bills cause significant administrative problems, as well as tarnish PPCWNY’s reputation of professionalism, and even unintentional violations of billing rules and regulations can be construed as fraud by state and federal authorities. Thus, billing errors as well as billing and payment improprieties of any kind (such as failure to return overpayments) may expose PPCWNY, as well as the individuals responsible for the billing problems, to substantial penalties, including criminal sanctions for false claims.
All health care professionals involved in preparing PPCWNY billing information and all employees and agents that perform technical or clerical tasks in connection with preparing or submitting this billing information, are required to become familiar with and abide by all applicable laws and regulations, including the particular coding and billing rules of Medicaid and other pertinent third-party payers. Among other things, employees must ensure that PPCWNY does not:
bill for patients not actually served by PPCWNY
bill for services not ordered by a qualified provider (RN, PA, NP, MD, DO)
bill for services not signed by a qualified provider-e-signature is acceptable
bill more than once for the same service
bill for services the employee knows are also being billed to the government by another healthcare provider
bill for a service (or level of service) not actually provided to the patient by PPCWNY
bill the Medicaid program as the primary payer when the patient has other public or private health insurance
bill for a service where a licensed provider has not seen the patient unless the third- party payer allows it.
It is critical that Medicaid and other payers be billed only for medically necessary services which are properly documented and for which they are properly accounted. PPCWNY is committed to this level of achievement and performance by its staff and shall provide training opportunities to support this end.
The failure of an employee to adhere to all applicable billing rules may subject PPCWNY to substantial liability. Among other things, it is a violation of the False Claims Act to knowingly submit a false claim or fraudulent claim for payment to a federal program such as Medicaid or Medicare. PPCWNY may be subject to treble damages (i.e., three times the amount of the false claims) and civil monetary penalties of up to $25,0761 per claim under the False Claims Act. Other state and federal laws impose civil and criminal penalties on PPCWNY and its employees for improper billing activity.
In addition to these basic billing standards, the following also applies to PPCWNY billing activities:
Periodic sample internal chart and billing reviews shall be conducted. This shall include review of the bill against the patient record to assure that billing is proper and that there was no upcoding, down coding, unbundling of services or other improper maximization of reimbursement (see Coding for Services, below).
Corrective action shall be taken to address any issues demonstrating non- compliance and requiring training, re-training, disciplinary action, reconciliation with payer or policy changes by PPCWNY.
Medical Record Documentation.
Documentation in the medical record must support the services or procedures selected for billing. Medical records:
notes, and other documents shall be appropriately organized
documentation is timely
The documentation of each patient encounter includes the reason for the encounter, any relevant history, physical examination findings, prior diagnostic test results, assessment, clinical impression or diagnosis, plan of care, and date and legible.
CPT and ICD-10 codes used for claims submission are supported by documentation in the medical record.
Appropriate health risk factors are identified. The patient’s progress, their responses to treatment.
PPCWNY maintains a process for identifying and reviewing its billing and coding to ensure compliance with applicable state and federal requirements.
The identity of the individual providing the service shall always be included in the medical record documentation by signature or electronic log-in
Health professionals shall exercise due care and diligence to assure the accuracy and completeness of all medical records and charge tickets. The appropriate health professionals shall (electronically) sign the medical record to verify that the service was performed and documented in the medical record, and that the level of care and diagnosis are accurate.
PPCWNY has a medical record consultant to perform audits of medical records to confirm their accuracy.
Coding for Services.
Appropriate and accurate codes shall be used for services provided. For example, “upcoding” is a violation of PPCWNY policy. “Upcoding” means that a provider designates a billing code for services that they know or should know will result in greater payments than the provider is otherwise entitled to receive. “Down coding,” the opposite of “upcoding,” means that a provider designates a billing code for services that they know or should know will result in a lesser payment than the provider is otherwise entitled to receive. “Unbundling” means billing separately for services where payers require that the services be billed together.
It is the responsibility of personnel at PPCWNY including all clinical staff, to ensure that the codes reported on the charge ticket or information otherwise provided to the billing department are supported by documentation and/or narratives in the medical record for each treatment or service furnished.
A. Submitting Complete and Accurate Reports to Government Agencies
Under certain programs, PPCWNY’s reimbursement from the government may be based, in whole or in part, on PPCWNY’s costs. In these programs, PPCWNY is required to submit regular cost reports, which are used by the funding agency to determine the total cost reimbursement owed to PPCWNY. All employees involved in the process of preparing and submitting cost reports must strive to ensure that these reports are accurate and complete. Expenses reflected on cost reports must have been incurred and properly allocated in accordance with program guidelines. The same standards of accuracy and completeness apply to any other reports or data regarding PPCWNY’s operations submitted to government agencies, private funding sources, or federal and state grant programs such as the Title X Family Planning Program and the NYS Family Planning Grant.
B. Avoiding Conflicts of Interest
Employees are required to act solely in the best interests of PPCWNY when carrying out their job responsibilities and must avoid all activities that constitute or create the appearance of a conflict of interest. Employees may not accept any gift or gratuity from any pharmaceutical firm or its supplier to PPCWNY or from any provider/potential provider of service (vendor) to PPCWNY, other than unconditional gifts of nominal value. No gifts of cash or cash equivalents are permitted. The employees are prohibited from using their position with PPCWNY for personal benefit. For example, employees are prohibited from facilitating contracts between PPCWNY and companies in which they have a financial interest.
PPCWNY’s directors and officers are also required to avoid conflicts of interest. Among other things, they are prohibited from voting on or otherwise influencing the implementation of business arrangements between PPCWNY and the director/officer or a company in which the director/officer has a financial interest.
All Board of Directors submit an annual Conflict of Interest disclosure.
C. Using Agency Resources Exclusively for Agency Business
Employees may use PPCWNY resources solely for the purpose of carrying out their job responsibilities. PPCWNY’s facilities, equipment, staff and other assets may not be used by an employee for personal benefit or to engage in any outside business or volunteer activity without the prior approval of the CEO. Employees may not use their affiliation with PPCWNY to promote any business, charity or political cause.
Employees shall seek reimbursement for expenses only to the extent such expenses have been incurred while carrying out their job duties and in accordance with PPCWNY’s expense reimbursement policies.
D. Using Agency Resources Exclusively for Charitable Purposes
PPCWNY is a tax-exempt organization under Section 501(c)(3) of the Internal Revenue Code. This status generally requires PPCWNY to engage in only those activities that are within its approved charitable purpose. PPCWNY is a nonprofit organization that provides reproductive health care to men and women in the Central and Western New York area. PPCWNY is licensed by NYS Article 28 of the public health law. Employees may not use PPCWNY’s resources to engage in any business activity, even if for PPCWNY’s benefit, that is outside the scope of PPCWNY’s charitable purpose without the approval of the CEO in consultation with counsel.
E. Ensuring Equal Opportunity for all Patients, Employees and Contractors
PPCWNY is committed to serving all patients on an equal basis without regard to race, nationality or ethnic origin, religion, gender, age, gender identity, sexual orientation, disability, immigration status, or any other personal characteristic or status with respect to which discrimination is barred by law.
Discrimination on these grounds is also prohibited in connection with the hiring and treatment of employees and contractors. In addition, sexual harassment of employees or patients will not be tolerated. PPCWNY seeks to create an environment in which the dignity of each individual is fully respected.
F. Maintaining the Confidentiality of Patient Records
All patient records must be kept confidential in accordance with applicable privacy laws and regulations. PPCWNY is subject to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Health Information Technology for Economic and Clinical Health of 2009 (HITECH), which limits the use and disclosure of protected health information.
PPCWNY must also comply with special state confidentiality laws governing HIV- related information. PPCWNY has adopted a comprehensive privacy compliance program governing the use and disclosure of patient records. All employees who have access to such records must familiarize themselves with this program’s policies and procedures and adhere to their terms.
G. Conducting all Business with Honesty and Integrity
PPCWNY is committed to conducting all its activities with honesty and integrity. Independent contractors who provide services that relate to billing, payment, ordered services, medical necessity, quality of care, governance, mandatory reporting, or credentialing must comply with PPCWNY’s Compliance Program. Independent contractors who do not comply with PPCWNY’s Compliance Program is subject to termination of their contract. Employees and independent contractors are expected to act in a manner that promotes PPCWNY’s reputation as an organization that exceeds the strict requirements of the law and operates in accordance with the highest ethical standard