Community Behavioral Health Services - San Francisco Department ...

Compliance (Mental Health and Substance Abuse)The San Francisco Department of Public Health is firmly committed to full compliance with all federal and statelaws, regulations, rules, and guidelines that apply to its operations and services. To emphasize this, DPH hasdeveloped a Compliance Program to assist in the detection, resolution, and prevention of any violations ofregulations. These are the seven key elements of the DPH Compliance Program – as identified by the Office ofthe Inspector General:1. The commitment of leadership2. Written policies and procedures, including standards of conduct3. Education and training of staff on compliance4. Enforcement of compliance standards5. Monitoring and auditing of eligibility, claims, billing, cost reporting, documentation, and record-keepingprocedures6. A process to detect violations and implement corrective action7. A process - such as the use of a Hotline - for reporting known or suspected compliance violations.Coding and billing are areas of particular importance in regulatory compliance. Departmental guidelines foraccurate coding and billing state the following:• DPH shall follow recognized guidelines for accurate coding approved by the Center for Medicare andMedicaid Services (CMS).• All DPH service areas will utilize current billing codes, including those established or approved by CMS,the California Department of Health Services (DHS), and the Department of Mental Health (DMH), andas authorized in the Health Insurance Portability and Accountability Act (HIPAA).• All codes reported for claims and billing must be supported by complete documentation in the patientrecord. Providers or their representatives should not assume a particular code applies to a service, butshould verify the accuracy of all codes used.• DPH Information Systems staff must coordinate with program and/or patient accounting staff tomonitor computer software used in coding and billing.• Staff with job functions that involve coding or billing shall be given ongoing training when codes and/orrules are modified or updated.• Billing units must regularly examine Explanation of Benefits (EOB), payer Remittance Advices (RA), andclaim denials to identify billing accuracy issues and changes in reimbursement policies and procedures.Feedback should be provided to employees, through regularly scheduled meetings, regarding denials,documentation compliance, and results of charging patterns and reimbursement levels.• Policies and procedures on coding, billing, and reimbursement should be outlined in manuals andguidelines within each division. Staff should be trained on the use and scope of the manuals andshould be asked to acknowledge, in writing, that he or she understands the policies outlined therein.• DPH billing departments should maintain adequate references and tools to assist staff in performingtheir job tasks. These references should be kept updated by managers and supervisors and mayinclude printed material as well as Internet/intranet links to policies, rules and regulations.• Staff should have a system available to express any concerns regarding coding and billing practices.Such concerns should be discussed with a supervisor or referred to the Compliance Officer, or to theCompliance Hotline at 642-5790.• In the event that billing inaccuracies are discovered (as a result of routine monitoring, EOB/RAanalysis, review of claims denials, or through staff reporting) they should be reported to theappropriate department manager or supervisor. An action plan to correct and prevent furtheroccurrences will be promptly developed and implemented.• For more information, please call the Performance and Compliance Section at 255-3723.94