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Willow Creek Physician Office
By: Andrea Anselme & Carly Bethea
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Mission Statement:
Willow Creek Physician Office strives to be a leader in the excellence of patient centered care by
providing compassionate lifelong services with health professionals you can trust. Patient care is
our passion, and it is a privilege to serve our community.
Vision Statement:
Our goal for the patients experience is to deliver quality satisfactory health care that we would
expect for our own family. We hope that through our devoted care and teamwork we improve the
lives of those we serve.
We Value:
Integrity
Well-being
Teamwork
Devotion
Trust
Quality care
Knowledge
Patient-Physician Relationships
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Code of Ethical Conduct
Willow Creek’s Code of Ethical Conduct ensures that we are honoring our mission, vision, and
value statements. These ethics reflect the behavior of our staff in all situations.
Ethical Principles:
I. Law-abiding: We use current processes that are compliant with the HIPAA
Privacy Rule. The security of our patients’ medical information is of our upmost
concern.
II. Compassion: Willow Creek’s faculty and staff have a passion for patient care. We
have empathy for all of our patients and their needs.
III. Diversity: We treat all patients equally regardless of race, ethnicity, religion, or
gender. To the best of our ability, we assist customers with communication
barriers.
IV. Excellence: Our faculty and staff are dedicated to providing excellence in care by
treating patients with compassion and dignity.
V. Honesty: Patients can put their trust in Willow Creek’s character and values for
all of their healthcare needs. We always focus on the best interests of our patients
by maintaining honesty and gaining trust through patient relationships.
VI. Commitment: Our physicians are devoted to expanding their medical knowledge
to provide the best information and care for their patients.
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Code of Conduct Form
I,___________________________________, have fully read and understand Willow
Creek’s Code of Ethical Conduct. I accept the terms and acknowledge that they must be
followed as long as I am employed by this company.
____________________________ ___________________
Employee Signature Date
___________________________ ____________________
Supervisor Signature Date
4
Compliance Officer Duties
1. Preferred Credential: Certified Medical Compliance Officer (CMCO)
2. Oversee corporate compliance program
3. Develop and implement policies and procedures
4. Evaluate areas of a risk and inform departments of corrective action plan
5. Create and enforce compliance training program
6. Educate other departments on compliance issues
7. Monitor and supervise compliance activities
8. Promote and lead compliance committee meetings
9. Communicate Standards of Conduct
10. Authorize management of the Compliance Hotline
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Compliance Officer
Mary Anderson, Ph.D., MS, RHIA, CMCO Willow Creek Physician Office Compliance Officer
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Compliance Committee Duties
1. Have general knowledge about compliance and quality issues within Willow Creek
Physician Office.
2. Attend quarterly meetings to monitor progress and effectiveness of compliance plan.
3. Recommend improvements for areas lacking in compliance and make necessary
changes.
4. Ensure consistent communication throughout the office by educating staff on
compliance issues, improvements, and clarifications.
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Compliance Committee Members
Henry Johnson, RHIA Health Information Manager
Megan Phillips, FNP-BC Family Nurse Practitioner
Sarah Young, JD Healthcare Attorney
Jeff Clark , MD Family Physician
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Risk Areas
1. Billing
a. Billing for items or services not rendered or provided as claimed
b. Submitting claims for equipment, medical supplies, and services that are not
reasonable and necessary
c. Double billing resulting in duplicate payment
d. Billing for non-covered services as if covered
e. Knowing misuse of provider identification numbers which results in improper billing
2. Coding
a. Unbundling (billing for each component of the service instead of billing or using an
all-inclusive code)
b. Failure to properly use coding modifiers
c. Clustering
d. Up coding the level of service provided
e. Under coding
f. Limited knowledge of coding rules and coding clinics
3. Documentation
a. Untimely
b. Inaccurate, incomplete, and illegible
c. CPT and ICD-9 CM codes not used for claim submission or supported by
documentation and the medical record
d. Inappropriate completion of HCFA 1500 form
4. Improper Inducements, Kickbacks, Self-Referrals
a. Financial arrangement with outside entities to whom the practice may refer federal
healthcare program business
b. Joint ventures with entities supplying goods or services to the physician practice or its
patients
c. Soliciting
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Billing
Policy
Willow Creek Physician Office should follow all federal regulations regarding billing by
ensuring: that billed items and services are rendered to the patient, all claims are
reasonable and necessary, billing is not duplicated or for non-covered services, and no
misuse of provider identification numbers. Quarterly reviews will be completed to
guarantee compliance with our policy. All billing is required to be accurate and truthful;
no staff member should ever misrepresent charges on behalf of third party payors.
Procedure
I. Prevention of Billing Items and Services not Provided to Patients
a. Evaluate patient charts for correct source of payment.
b. Ensure accuracy of billed services that pertain to documented patient visit.
c. Communication with other personnel within the office for clarification.
II. Prevention of Claims that are not Reasonable and Necessary
a. Educate staff and ensure understanding of Federal False Claims Act.
b. Using a computer system to identify false claims before billing.
c. Internal and External monitoring for uncertain billing behaviors.
III. Prevention of Billing that is Duplicated or for Non-Covered Services
a. Ensure each patient is only assigned one identification number.
b. Confirm accuracy of itemized bill for duplication errors before administering
to patient.
c. Check coverage and ask questions before services are rendered.
i. Understand patient benefits before admission.
ii. Patients with non-coverage of services should have their options explained
in addition to secondary reimbursement plan.
IV. Prevention of Misuse of Provider Identification Numbers
a. Avoid revealing identification number and password to other staff members.
b. Log out of all computer systems before leaving computer station unattended.
c. Refrain from asking other personnel to complete work under identification
number.
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Coding
Policy
Willow Creek Physician Office complies with the federal regulations as well as the
following standards: bundling billing components, proper use of coding modifiers,
prevention of clustering and up coding, and abiding by coding regulations. Employees
will maintain a high level of professionalism and ethical behaviors while performing
these procedures. Adherence to these guidelines is essential.
Procedure
I. Prevention of Unbundling Billing Components
a. Outsourcing staff to review and audit charts for unbundling.
b. Proper education and training for coders on how to bundle multiple
components under a single fee.
c. Coders must use all-inclusive codes when necessary.
II. Proper use of Coding Modifiers
a. Coders must reference sections of the Medicare Provider Manual to ensure
appropriate use of modifiers.
b. Consult National Correct Coding Initiative (NCCI) for coding modifier
clarification.
c. Remain updated on NCCI coding edits.
III. Prevention of Clustering and Up Coding
a. Monitoring and proper use of the encoder.
b. Abiding by the laws set by CMS regarding clustering and up coding.
c. Audit claims monthly to ensure services and procedures rendered align with
what was coded.
IV. Abide by Coding Regulations
a. Following rules and guidelines in coding clinics.
b. Coders must have a background of clinical knowledge in pathophysiology and
anatomy & physiology.
c. Reference coding materials when questions arise and apply concepts
accordingly.
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Documentation
Policy
Willow Creek Physician Office should guarantee timely, accurate, and complete documentation
to improve the quality of clinical patient care. Documentation should comply with the Federal
Register. Proper documentation habits are necessary to receive full reimbursement from the third
party payor.
Procedure
I. Prevention of untimely documentation
a. Perform concurrent patient documentation.
i. Documented and completed during patient encounter
b. Provide physicians with incentives to complete documentation in a timely
manner.
c. Ensure that physicians reference The Documentation Guidelines for Evaluation
and Management Services.
II. Prevention of incomplete, inaccurate, and illegible documentation
a. Documentation of each patient encounter must include:
Reason for encounter
Any relevant history
Physical examination findings
Prior diagnostic test results
Assessment, clinical impression, diagnosis
Plan of care
Date and legible identity of the observer
b. Facilitating high quality patient care by properly documenting and verifying
what services were actually provided validates:
i. Site of the service
ii. Appropriateness of the services provided
iii. Accuracy of billing
iv. Identity of the caregiver
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c. Randomized audits by various selected staff member to ensure legibility of
physician documentation.
III. Ensure CPT and ICD-9 CM codes are used for claim submissions and are supported
by documentation and the medical record
a. The medical record chart must contain all necessary information reported on
the health insurance claims form.
b. Caregiver of service must be clear within the documentation.
c. Compare denial rates with other practices within the same specialty to identify
variances.
IV. Appropriate use of the HCFA 1500 form
a. Coders must link the diagnose code with reason for visit or service.
b. Ensure appropriate use of modifiers.
c. Under Medicare Secondary Payor policy, provider must inform Medicare about
beneficiaries other than insurance coverage if practice is aware.
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Improper Inducements, Kickbacks, and Self-
Referrals
Policy
Willow Creek Physician Office is committed to maintaining high ethical standards and ensuring
that physicians are complying with all applicable laws pertaining to the Anti-Kickback law. This
federal law prohibits healthcare providers and suppliers from soliciting, offering, paying, or
receiving prohibited remuneration. Our facility interacts with several physicians to provide high
quality care to our patients through adhering to this law.
Procedure
I. Prevention of inducements, kickbacks, self-referrals, and soliciting
a. To avoid inappropriate inducements to patients, our physician practice will obtain
and become familiar with the OIG special fraud alerts and advisory opinions.
b. If an employee is concerned with suspicious behavior regarding inducements,
kickbacks, or self-referrals, the Chief Compliance Officer must be contacted.
c. Gift giving must be monitored by the Chief Compliance Office to ensure
inducements do not influence business decisions.
II. Prevention of financial arrangements with outside entities and joint ventures entities
supplying goods or services
a. Physicians must not pay unreasonable or excessive compensation for goods and
services.
b. Any business arrangements must be reviewed by legal counsel familiar with the
Anti-Kickback Statute.
c. Business arrangements within Willow Creek Physician Office to an outside entity
will be in a fair market value basis.
15
Compliance Education and Training
Education:
Willow Creek Physician Office staff is required to attend quarterly in-person training sessions on
site to ensure necessary education is communicated effectively. After education sessions,
employees will have a better understanding of topics covered which include:
Job analysis of specific duties pertaining to job title
Availability of online resources
Technical support for unexpected occurrences or concerns
Awareness of upcoming changes
Information about future CE events
CMS newsletters
Training:
1. Four training seminars will be offered throughout the year at an outside facility. All new
and current employees must attend one of the training seminars annually. Information
covered will include:
Risk Area
Core Values
Staff Compliance
Quality Improvement
Patient Service Improvements
2. An officer of our compliance committee will present a seminar that includes an
interactive Power Point presentation followed by group activities.
3. When the seminar has ended, employees are required to take an assessment regarding
information that was covered to ensure retention of information.
Employees must score the assessment with a 90% or above to pass.
If employee does not pass the assessment within the first try, a second attempt is
allowed.
Failure to pass the second attempt, will require employee to attend another
seminar. Once the assessment is passed, the Training Completion Form must be
filled out to file with employee records.
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Training Completion Form:
I, _______________________________, have completed Willow Creek Physician Office
Training Seminar and:
Passed the training assessment
Understand the annual requirement attendance for each year of employment
Understand the quarterly requirement attendance for education sessions for the
duration of employment
________________________________________ __________________
Employee Signature Date
________________________________________ __________________
Compliance Officer Signature Date
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Compliance Hotline
The following compliance committee members may be contacted for any questions or
clarifications regarding our facility’s compliance plan:
Henry Johnson, RHIA Health Information Manager
Office: (309) 233-2399
Cell: (309) 867-5309
Fax: (309) 998-1121
Megan Phillips, FNP-BC Family Nurse Practitioner
Office: (309) 765-0234
Cell: (309) 897-4562
Office: (309) 550-4312
Sarah Young, JD Healthcare Attorney
Office: (309) 878-0983
Cell: (309) 772-0060
Fax (309) 330-7771
Jeff Clark, MD Family Physician
Office: (309) 454-9827
Cell: (309) 778-4421
Fax: (309) 555-6218
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Resources
1. Abdelhak, Grostick, Haken, Jacobs. Health Information: Management of a
Strategic Resource. 4th Edition. Saunders Company, 2011.
2. OIG.hhs.gov
3. Peden, Ann H. Comparative Health Information Management, 3rd Edition.
Thomson/Delmar Learning, 2012.
4. Tulareregional.org
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Disciplinary Guidelines
To remain reliable, honest, and trustworthy, Willow Creek’s employees must be compliant with
our physician office policies and procedures and federal laws. In an event of misconduct, the
following steps will be enforced based on employee action(s). There are four formal discipline
levels.
Step one:
Level I Reminder is a verbal warning given by the Chief Compliance Officer. The employee’s
misconduct is discussed during a meeting along with corrective action suggestions to prevent a
second occurrence of misconduct.
Step two:
Level II Reminder is a written warning that is recorded in the employee’s file. The Chief
Compliance Officer distributes the discipline form to the employee to sign. Completion of this
form signifies understanding of the misconduct and compliance with disciplinary actions.
Step three:
A Decision-Making Leave is the employee’s final chance to redeem their actions to remain
employed at Willow Creek. The employee is asked to leave work for the day and write an essay
explaining their actions. Their essay should include how they will actively work on steps to
prevent the action from happening again. The essay is reviewed by Chief Compliance Officer. If
the essay shows that the employee is taking their actions seriously and working on attainable
corrections, they will remain employed. If the essay shows lack of understanding and no
corrections, the employee will be terminated.
Policies to Remove Violators
When an employee carries out any of the following actions, the result is immediate termination:
Violates HIPAA
Violates Federal Laws
Displays fraudulent behavior
Performs illegal actions
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Level II Warning Form
To remain reliable, honest, and trustworthy, Willow Creek’s employees must be compliant with
our physician office policies and procedures and federal laws. I, _________________________,
have read/ understand my previous verbal warning and acknowledge the disciplinary actions that
are to follow. If my behavior continues, I recognize that I will be asked to take a Decision-
Making Leave that could result in termination.
Violation:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________ _________________
Employee Signature Date
_____________________________________ _________________
Compliance Officer Signature Date
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Decision-Making Leave Form
To remain reliable, honest, and trustworthy, Willow Creek’s employees must be compliant with
our physician office policies and procedures and federal laws. I, _________________________,
have read/ understand my previous Level II Warning and acknowledge the disciplinary actions
that are to follow. I recognize that I am being asked to leave work to write an essay explaining
my actions of misconduct and to express corrective solutions for my behavior. I understand that
after writing this essay, termination is a potential outcome.
_____________________________________ _________________
Employee Signature Date
_____________________________________ _________________
Compliance Officer Signature Date
22
Termination Form
To remain reliable, honest, and trustworthy, Willow Creek’s employees must be compliant with
our physician office policies and procedures and federal laws. I, _________________________,
understand that I have violated one or all of the following:
Willow Creek Physician Office policies and procedures
Violates HIPAA
Violates Federal Laws
Displays fraudulent behavior
Performs illegal actions
I understand that my signature indicates termination of employment and future employment
opportunities at Willow Creek Physician Office.
_____________________________________ _________________
Employee Signature Date
_____________________________________ _________________
Compliance Officer Signature Date
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Audits
Willow Creek Physician Office should be compliant with federal audit guidelines. A well-
designed compliance program can:
Speed and optimize proper payment of claims
Minimize billing mistakes
Reduce the chances of an audit being conducted by the HCFA or the OIG
Avoid conflicts with self-referral and anti-kickback statutes
Undergoing these periodic audits will help the office to maintain quality output throughout the
facility.
Periodic Audits:
Audits will take place once during each fiscal year after a baseline audit. The audits will occur at
random. The sample of medical records that will be selected for auditing is 8 per physician.
Since this office receives reimbursement from several payors, the auditing/ monitoring process
will consist of reviewing claims from all federal payors.
If a problem is identified in the audit, more extensive and frequent audits will occur. Problems
that were identified during the audit will have more attention focused on them for future training
and education.
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Investigation and Remediation of Systemic
Problems
Investigation:
If an issue arises, root cause analysis will be performed to locate the source of the problem.
Remediation:
1. Collaborate solutions to the problem
2. Choose the best solution
3. Implement the new process
4. Monitor the new process and gather feedback from employees that are involved with the
new implementation