University of Florida College of Medicine
Office of Compliance

BILLING COMPLIANCE INVESTIGATION GUIDELINES

June, 1999

These guidelines outline how the Office of Compliance
receives, documents and investigates allegations of billing non-compliance.

GUIDELINES

Compliance Plan -- University of Florida College of Medicine employees must comply with the University of Florida College of Medicine Billing Compliance Plan (the "Plan") and applicable state and federal law.

The Plan requires the Director of Billing Compliance (the "Director") or his/her designee (collectively, the "Office of Compliance") to investigate allegations of non-compliance.  The Plan also requires employees to report suspected incidents of billing non-compliance to the Office of Compliance and to cooperate with any investigation into allegations of non-compliance.

Protection of Rights -- To the greatest extent possible, the Office of Compliance will protect the rights of all College of Medicine employees during any inquiry, investigation or fact finding process, including taking steps to protect the privacy of the accused and of those who, in good faith, report alleged non-compliance.

No Recrimination -- The Plan forbids any recrimination toward a person bringing a good faith allegation of billing non-compliance.  Retaliatory conduct against persons acting in good faith will be subject to disciplinary action.  If it is found that an accusation has been brought maliciously or in bad faith, the filing of the accusation can be cause for disciplinary action against the complainant in accordance with College of Medicine rules.

Confidentiality -- To the greatest extent possible, the Office of Compliance will maintain confidentiality throughout any inquiry or investigation.  All individuals involved in the inquiry or investigation process will be informed of the confidentiality requirements.

Conflict of Interest -- The Office of Compliance will take precautions to avoid real or apparent conflict of interests of individuals involved in the inquiry or investigation process.

At the discretion of the Director, inquiries or investigations that may be in conflict with the interests of the Director will be referred to the Dean of the College of Medicine for resolution.  The Office of Compliance automatically will refer any inquiries or investigations involving the billing activities of the Director to the Dean of the College of Medicine for resolution.

Fair Process -- The Office of Compliance will conduct all inquiries and investigations in a fair and impartial manner.

PROCESS

Procedure -- The Office of Compliance has a duty to investigate and determine the appropriate responses to all reports and indications of suspected billing non-compliance and to oversee and coordinate resolution of all College of Medicine billing compliance issues (including follow-up, record keeping, research, communication and education).  A determination of the gravity of the compliance problem will dictate the speed of response and extent of investigative activities.

Coordination -- The Office of Compliance will coordinate any inquiry or investigation with the University of Florida Office of General Counsel.

Allegations of Billing Non-Compliance -- Allegations of billing non-compliance may be made by anyone who has reason to believe that such non-compliance has occurred.  Such allegations may be made directly to the Office of Compliance or through the Billing Compliance Hotline.

Initial Inquiry -- The Office of Compliance will perform an initial inquiry and determine whether there is evidence that billing non-compliance may have occurred. If evidence of billing non-compliance is found, the Office of Compliance will proceed with an investigation.

Discontinue Billing  -- After the initial inquiry, and throughout any subsequent investigation process, the Director may require that billing temporarily be discontinued for the provider involved in the alleged non-compliance or require pre-billing reviews of an affected provider's charts.  The Director also may require that a specific staff member be removed from their current billing-related work activity until the investigation is completed.

Investigation -- The Office of Compliance will perform an investigation if an initial inquiry has resulted in evidence that billing non-compliance has occurred.

With the assistance of the Office of General Counsel, the Office of Compliance will review College of Medicine policies, federal and state statutes and regulations, intermediary and carrier communications, medical society publications or other appropriate sources in order to identify the proper documentation or billing standard relative to the alleged billing non-compliance.  If there is ambiguity in the billing requirements, a determination of the appropriate policy will be made by the Director with guidance from the Office of General Counsel.

The Office of Compliance will secure all billing or patient record data (or other relevant information) involved in the allegation.  Such action will not constitute disciplinary action, but is meant to obtain and preserve the data or information.

Whenever possible, the Office of Compliance will interview all individuals involved in the alleged act of billing non-compliance, as well as other individuals who might have information regarding key aspects of the allegations.  These individuals may include, but are not limited to, College of Medicine and Shands employees.

Action Decision -- Upon conclusion of the inquiry or investigation, the Office of Compliance will prepare a written report of the findings of the inquiry or investigation.  The written report will indicate whether or not the investigation found credible evidence that billing non-compliance has occurred and whether or not corrective and/or disciplinary action is warranted.

In addition to the conclusion reached, the written report will state what documents were reviewed, summarize the relevant interviews and substantiate the findings of the inquiry or investigation. The Director will maintain documentation of the inquiry or investigation in a secure manner for at least three years following the termination of the inquiry or investigation.

Corrective/Disciplinary Action -- If the finding of the investigation is that billing non-compliance has occurred, the Director will determine any appropriate corrective action needed and will make a recommendation to the affected employee's supervisor as to appropriate disciplinary action.

When applicable, the Director will recommend the appropriate corrective or disciplinary action in accordance with the College of Medicine's existing remedial and disciplinary measures.  Examples of such remedial or disciplinary action include:

  1.   The issuance of a Letter of Counseling;
  2.   The issuance of a Letter of Reprimand;
  3.   Suspension without pay; and
  4.   Termination.
In addition, when applicable, corrective action also includes, but is not limited to:
  1.   Suspending billing for the affected provider's services;
  2.   Requiring pre-billing reviews of an affected provider's charts; and
  3.   Requiring an affected provider or staff member to attend educational seminars.
If corrective or disciplinary action is recommended, the Director will meet with the Chair of the non-compliant provider's Department or the supervisor of any non-compliant staff member to discuss any required corrective or recommended disciplinary action.

Decisions regarding faculty discipline will be made in accordance with University of Florida policies and procedures.

Reporting -- If, after a reasonable inquiry and investigation, the Office of Compliance has reason to believe that the non-compliance may violate criminal, civil or administrative law, then the Director may be required to report the existence of such non-compliance to the appropriate federal and state authorities.  Such incidents will be discussed with the Office of General Counsel in order to determine the appropriateness of reporting the non-compliance to any governmental agency.

SUBSEQUENT ACTION

Appeal -- If the Department Chair or individual involved in the non-compliant activity does not agree with the proposed corrective or disciplinary action, the Department Chair or individual may appeal the issue in accordance with University of Florida disciplinary policies and procedures.

Inform and Educate  -- The Office of Compliance will inform the non-compliant provider or staff member and his/her Department Chair of any immediate corrective action in billing procedure and the reasons for any such changes.

Subsequent Audits -- The Office of Compliance may direct the appropriate Department to perform post-investigation medical record and claim reviews to monitor compliance with any final decisions of the Director.  The Office of Compliance also may perform additional audits or review the departmental audits as necessary.

Further Action  -- The Director may recommend additional action if departments or individuals continue to be out of compliance with final decisions of the Director.

ADDITIONAL INFORMATION

Questions regarding these Guidelines should be directed to the Office of Compliance at 352-265-8359.  In addition, the College of Medicine 24-hour Gator Billing Compliance Hotline can be reached at 1-866-574-2867.



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