Office of Compliance

COLLEGE OF MEDICINE
BILLING COMPLIANCE PLAN

Reviewed January 2011¹

1.0  Introduction

1.1  The University of Florida College of Medicine (the "University") has a strong and abiding commitment to ensuring that its affairs are conducted in accordance with applicable law.  A critical focus of any compliance plan for an academic health center relates to professional fee reimbursement. Compliance in this area is challenging because the regulatory requirements governing such reimbursement continue to be complex and changing.  To underscore and enhance its commitment and to better assist all employees, including faculty physicians, the University has formalized a Compliance Plan for professional fee reimbursement (the "Plan") which draws together and builds upon existing compliance mechanisms.  The Plan has the following key features:

1.1.1  Designation of University officials responsible for directing the effort to enhance billing compliance, including implementation of the Plan;

1.1.2  Incorporation of standards and policies that guide University personnel with regard to professional fee billing;

1.1.3  Development, implementation, monitoring and updating of compliance initiatives at the Department level, including those department divisions based in other cities, such as Jacksonville;

1.1.4  Coordinated training of clinical staff and billing personnel concerning applicable billing requirements and University policies;

1.1.5  Provision of a uniform mechanism for employees to raise questions and receive appropriate guidance concerning professional fee billing;

1.1.6  Regular chart and billing reviews by University employees (and external consultants, as necessary) to assess compliance and to identify potential issues;

1.1.7  A process for employees to report instances of possible non-compliance and for such reports to be fully and independently reviewed;

1.1.8  Regular reviews of the overall compliance effort, including Department specific plans, to ensure that billing practices reflect current requirements and that other adjustments are made to improve the program; and

1.1.9  Formulation of corrective action plans to address any instances of non-compliance with University policies or billing requirements.

1.2   The University has faculty based in Gainesville and Jacksonville who function under University of Florida Board of Trustees designated faculty practice plans².   The Plan described in this document is intended to establish a framework for legal compliance by the University's activities at both the Gainesville and Jacksonville campuses.  It is not intended to set forth all of the substantive programs and practices of the University that are designed to achieve compliance. The University already maintains various compliance practices and those practices continue to be a part of its overall legal compliance efforts.

2.0  Director of Compliance

2.1  Responsibility for implementing and managing the Plan on the Gainesville campus is assigned to a Director of Compliance who is appointed by and reports directly to the Dean of the College of Medicine.  The Director of Compliance for the Gainesville operations oversees and is supported by the staff of the Gainesville Office of Compliance.

2.2  Responsibility for implementing and managing the Plan on the Jacksonville campus is assigned to a Director of Compliance who is appointed by and reports directly to the Senior Associate Dean of the College of Medicine in Jacksonville (the "Senior Associate Dean"), with the concurrence of the Dean of the College of Medicine.  The Director of Compliance for the Jacksonville operations oversees and is supported by the staff of the Jacksonville Office of Compliance.

2.3  As used in this Plan, the term "Directors" designates the Director of Compliance for Gainesville and the Director of Compliance for Jacksonville as they perform and oversee the duties of the Director of Compliance at their respective locations.

2.4  To facilitate communication of ideas and assure uniformity in compliance activities on the Jacksonville and Gainesville campuses of the College of Medicine, the Directors will ensure regular and frequent communication occurs between their offices.  In addition, an Executive Committee will be established.  The Executive Committee will be comprised of the Directors and selected faculty and administrative representatives from the local compliance committees on the Jacksonville and Gainesville campuses as well as the divisional compliance leaders from other outlying sites.  This Executive Committee will meet on a quarterly basis.

3.0  Duties of the Director of Compliance

3.1  The Directors shall chair a Compliance Committee based in their respective location.  The Compliance Committee will meet regularly to address compliance issues and will consist of: (a) appointed representatives from the Dean's office; (b) the Compliance Leaders of each College of Medicine clinical department; and (c) appointed representatives of University billing entities.

3.2  The Directors will, with assistance of counsel where appropriate, perform the following activities:

3.2.1  Review, revise, and formulate appropriate policies to guide billing of professional fees by the College of Medicine for services provided by its employees;

3.2.2  Oversee the review, revision and approval of Department compliance plans, including Department policies relating to billing and documentation;

3.2.3  Review and approve training materials and programs;

3.2.4  Oversee compliance chart and billing reviews conducted by both internal and external auditors/consultants;

3.2.5  Review inquiries concerning billing issues related to compliance or reports of non-compliance by determining whether a compliance issue exists and, if so, develop an appropriate response; and

3.2.6  Develop appropriate corrective action plans to address compliance issues.

3.3  The Directors shall work closely with representatives of the Dean's office, the Departments and billing personnel (including the University of Florida Faculty Group Practice³, the Florida Clinical Practice Association, the University of Florida Jacksonville Physicians and any other billing organizations for the College of Medicine) to foster and enhance compliance with all applicable billing requirements.

3.4  The Directors shall have the authority to direct specific billing practices, including, but not limited to: (a) the use of particular codes for designated services; (b) the procedures and practices used to handle billing; and (c) the imposition of restrictions on billing by particular physicians, or groups of physicians, or other health professionals.

3.5  Before directing specific billing practices, the Directors should consult with other University personnel, including, for example, the Chair or Associate Chair of the affected department and administrative personnel in the billing department, in an effort to resolve issues through consensus.  The authority of the Directors of Compliance shall extend to all billing for clinical services -- whether on a fee for service basis or otherwise -- provided by University employees.

4.0  Policy Guidelines

4.1  It is the University's policy that all claims for professional fee reimbursement use the proper code for the service provided, that the documentation in the medical record supports the code, and that the claim is submitted in the name of the appropriate provider.

4.2  To guide physicians, other health professionals and billing personnel in meeting this objective, the Directors shall, with the assistance of the Office of Vice President and General Counsel, review existing policy statements, revise those statements as necessary, and develop any additional statements that seem advisable.

4.3  University policies concerning billing, as those policies may be changed periodically, should be considered an integral part of this Plan.

5.0  Departmental Compliance Leaders

5.1  The Directors shall ensure that each clinical department has appointed a Departmental Compliance Leader.  The Departmental Compliance Leader shall participate as a member of the Compliance Committee.

5.2  The Directors will coordinate departmental compliance activities with the Departmental Compliance Leaders.

5.3  The Directors will develop a program to ensure regular contact with the Compliance Leaders through the actions of the Compliance Committee.

6.0  Departmental Billing Compliance Plans

6.1  Each clinical department shall prepare a Departmental Billing Compliance Plan to address compliance efforts on a departmental basis.  This plan will address compliance issues for all clinical venues of the department.  In consultation with the appropriate Director, each department's Compliance Leader will develop a single departmental plan.  Before becoming effective, such plans shall be reviewed and approved by the Directors to ensure consistency with overall policies.

 6.2  If the Directors have concerns about the content of any departmental plan, the Directors should consult with the Department Chair or Associate Chair, the Dean, the Senior Associate Dean and/or appropriate representatives of the Faculty Group Practice to explore whether the plan can be modified through mutual agreement.  If such consultations fail to resolve the Directors' concerns, the Directors shall have the authority, with the approval of the Dean of the College of Medicine or the Senior Associate Dean, to modify the Departmental Billing Compliance Plan.

 6.3  The Departmental Billing Compliance Plans shall, at a minimum, include the following features:

6.3.1  Written policies and procedures for any billing activities undertaken by departmental personnel;

6.3.2  Educational and training programs, as coordinated with the Directors and the Faculty Group Practice, to address billing issues of particular importance to the department;

6.3.4  An annual review of the existing Departmental Compliance Plan in order to identify the need for changes and to identify specific compliance objectives during the succeeding year.

7.0  Education and Training

7.1  The Directors shall be responsible for ensuring that the University policies concerning billing are disseminated and understood.  To accomplish this objective, the Directors will work with the Office of Compliance, the Office of Vice President and General Counsel, representatives of the Dean, the Departments, and the Faculty Group Practice or other billing organizations to ensure that there is a systematic and ongoing training program that enhances and maintains awareness of billing policies among existing staff and that introduces new personnel to University billing policies.  The training materials will identify the specific people who should be contacted by physicians or billing personnel about billing questions.

7.2  All training materials directed to billing issues will be submitted to the Directors for review and approval before implementation.

7.3  Training shall be mandatory for all physicians or other health professionals within the College of Medicine who bill for their services, and College of Medicine billing personnel.  A system will be developed to document that such training has occurred.

7.4  The Directors can require that physicians, other health professionals who bill for their services, and/or billing personnel, attend training sessions on particular compliance issues.

7.5  No outside billing consultant may be retained by the Faculty Group Practice, the College of Medicine, or any Department or division, without the review and concurrence of the Directors.  If there is a disagreement about the need or appropriateness of seeking such consultation or about the suitability of the proposed consultant, the Dean of the College of Medicine or the Senior Associate Dean shall make the final decision about whether the consultant should be retained.

8.0  Monitoring

8.1  Under the supervision of the Directors, each clinical department will be audited by the Office of Compliance to monitor for compliance with the College of Medicine Billing Compliance Plan and with legal requirements.

8.2  If the Directors deem it appropriate, the Directors may, in consultation with the Dean of the College of Medicine, the Senior Associate Dean and the Office of Vice President and General Counsel, engage an external billing expert to assist with the audit process.

9.0  Reporting Compliance Issues

9.1  All compliance related training materials will direct University employees to report to the Directors any activity that they believe to be inconsistent with University policies or legal requirements regarding billing.  Such compliance related training materials also will explain how the Directors can be contacted and provide the employees with information about programs and practices of the University that are designed to achieve compliance with legal requirements.

9.2  Employees who report in good faith possible compliance issues shall not be subjected to retaliation or harassment as a result of the report.  Concerns about possible retaliation or harassment should be reported to the Directors.

10.0  Investigating Compliance Issues

10.1  Whenever conduct that may be inconsistent with a billing policy or requirement is reported to the Directors, an investigation will be undertaken with the assistance of the Office of Vice President and General Counsel.

10.2  University employees must cooperate fully with any investigations undertaken by the Directors, the Office of Vice President and General Counsel, or the Office of Audit and Compliance Review.

10.3  After review and investigation, the Directors will prepare a written report of findings.

10.4  If the Office of Vice President and General Counsel determines that the report may constitute a report under Florida's Whistle-blower's Act (F.S. 112.3187 et seq.), the Office of Vice President and General Counsel will direct the matter to be referred to the Chief Audit Executive of the University for handling pursuant to that statute.

11.0  Corrective Action Plans

11.1  Whenever a compliance issue has been identified, through monitoring, reporting of possible issues, investigations, or otherwise, the Directors shall develop a corrective action plan to address that issue.  In developing a corrective action plan, the Directors should obtain advice and guidance from the Office of Vice President and General Counsel.  There should be consultation with the Dean, the Senior Associate Dean and appropriate clinical and billing personnel.  Corrective action plans should be designed to ensure not only that the specific issue is addressed but also that similar problems do not occur in other areas or departments.

11.2  Corrective action plans may require that billing be handled in a designated way, that certain training take place, that restrictions be imposed on billing by particular physicians or other health professionals, that repayment be made, or that the matter be disclosed externally.  Sanctions or discipline, in accordance with University rules, also may be recommended.

11.3  If it appears that certain individuals have exhibited a propensity to engage in practices that raise compliance concerns, the corrective action plan should identify actions that will be taken to prevent such individuals from exercising substantial discretion with regard to billing.

12.0  Revisions to this Plan

12.1  This Plan is intended to be flexible and readily adaptable to changes in regulatory requirements and in the health care system as a whole.  The Plan should be regularly reviewed to assess whether it is effective and should be changed as experience shows that a certain approach is not effective.

12.2  To facilitate appropriate revisions to the Plan, the Directors should periodically prepare a report that describes the general compliance efforts that have been undertaken during the preceding period and that identifies any changes that might be made to improve compliance.  This report should be circulated to the Dean of the College of Medicine, the Senior Associate Dean for Jacksonville and to others with an interest in compliance for their comments about possible revisions to the plan.

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^{1 Replaces June 1996, February 1997, December 1998, and October 2000 Plans.
2 It is understood that the University of Florida has employed faculty based in other locations outside of the Gainesville or Jacksonville campuses and that these faculty are affiliated with clinical departments on the Gainesville or Jacksonville campuses.  Responsibility for billing compliance oversight for faculty based in these other locations shall come under the jurisdiction of the Office of Compliance of the affiliated campus.
3 References to the Faculty Group Practice in this Plan shall incorporate any entity or division that handles professional fee billing for University College of Medicine faculty or employees.}

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