OIG
Effective Compliance Program - Element # 1
(Part Three)by A. Maureen Hanna
OIG
Effective Compliance Program - Element # 1
(Part Three)
by A. Maureen Hanna
Element # 1 - Implementing written policies, procedures and standards of conduct. (Continued)
The supplier's compliance program should ensure services are billed only if they were ordered by the treating physician, have been provided, are covered, and are reasonable and necessary for the patient. The Medicare Carriers Manual (MCM) defines the requirements for orders, written orders required prior to delivery, certificates of medical necessity (CMN) and proof of delivery.
To assist DMEPOS supplier personnel the compliance program may include:
Summary of medical necessity and/or coverage
criteria that is clear and comprehensive.
Policies and procedures that include
periodic claims review both prior to and subsequent to billing
for items and services.
Policy that the supplier will not
bill for an item or service until it has been ordered by treating
physician or other authorized persons. If based on a verbal order,
state the requirements for documentation of such.
For items that require a written
order prior to delivery (e.g. seat lift mechanisms, power operated
vehicles, transcutaneous electronic nerve stimulators, decubitus
care items) the policy and procedure should state that the order
must be received by the supplier before it delivers the equipment
to the patient and before it bills the payer. Clearly define "received
by the supplier" along with examples.
For items requiring a CMN the supplier
must receive a signed CMN from the treating physician or other
authorized personnel. The original CMN must be retained in the
supplier's file and/or the ordering physician. Clearly define
your policy on where the original will be maintained. Since the
supplier is responsible for any repayment of funds under their
provider number, I strongly suggest the original be kept there.
The CMNs contain four sections (A,B,C,
and D). Your policy should clearly reflect the standards for completing
each section (e.g. Section B may only be completed by the treating
physician, a non-physician clinician involved in the care of the
patient or a physician employee who is knowledgeable about the
patient's treatment. If someone other than the physician completed
Section B, their name, title and employer must be reflected).
At minimum your policies and procedures should required that:
Do's
...you do maintains completed
and signed CMNs in you files;
...you do consults with the treating
physician or other authorized person who signed the CMN when there
is a question on the order;
...you do properly complete sections
A and C of the CMN and then forward the CMN to the treating physician
or other authorized person for his/her review, information, and
signature; and
...you only submit claims for services
that the treating physician or other authorized person attests
in section D are ordered and medically necessary for the patient.
Do Not's
...you do not forward blank
CMNs to the treating physician or other authorized person for
signature;
...you do not complete section B
(Medical Necessity) of the CMN;
...you do not alter or add any information
on the CMN after receiving the completed and signed CMN from the
physician or other authorized person;
...you do not sign the CMN for the treating physician or other
authorized person;
...you do not urge physicians or
other authorized persons to order equipment or supplies that exceed
what is reasonable and necessary for the patient;
...you do not deliver an item that requires a written order from
the treating physician or other authorized person prior to receiving
the written order;
...you do not submit a claim for
DMEPOS items or services prior to receiving a written order or
CMN from the treating physician or other authorized person;
...you do not submit a claim for DMEPOS items or services until
the CMN is properly and correctly completed by the treating physician
or other authorized person;
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