VitalityRCM

Emerson Nutritional recognizes that suppliers of durable medical equipment and supplies face unique challenges in the detection and prevention of fraud and abuse. Therefore, it has adopted this appendix to assist Emerson Nutritional in identifying specific risk areas.

Emerson Nutritional is committed to establishing a culture among its co-workers that promotes prevention, detection, and resolution of instances of conduct that do not conform to federal and state law; federal, state and private payors’ health care program requirements, as well as Emerson Nutritional ‘S own ethical and business policies. In order to promote this culture, Emerson Nutritional has established its Corporate Compliance Program, including a Code of Conduct (“Code”) that reflects this mission. Additionally, the Compliance Program includes Policies and Procedures that set out the means by which the Code will be implemented and monitored by Emerson Nutritional . These policies and procedures incorporate the seven elements that the Department of Health and Human Services (“DHHS”) has identified as fundamental to an effective compliance plan. Furthermore, they set out in detail Emerson Nutritional ‘S procedures concerning fraud and abuse oversight responsibilities; co-worker training and dissemination of information; mechanisms for auditing and monitoring; mechanisms for the reporting of violations/investigation of reports; and policies concerning enforcement and discipline for violations. In addition to these policies and procedures, Emerson Nutritional adopts the following policy elements applicable to:

A. Claims Development and Submission. The DME program will take all reasonable steps to ensure that its employees do not submit claims unless they are

1. reasonable;
2. covered; and
3. medically-necessary

The Emerson Nutritional program will not bill for an item unless and until it has been ordered by the treating physician or other authorized person, and will ensure that a signed Certificate of Medical Necessity (CMN) is obtained where appropriate.

B. Marketing. Where appropriate, the Emerson Nutritional compliance program will maintain policies and procedures to ensure honest, straightforward, fully-informative and non-deceptive marketing.

C. Identifying Risk Areas. As part of its compliance program, and where appropriate, Emerson Nutritional will maintain records or develop policies and/or procedures to address the following risk areas:

1. Billing for items or services not provided.
2. Billing for services that the DME supplier says may be denied.
3. Billing patients for denied charges without a signed written notice.
4. Duplicate billing.
5. Billing for items or services not ordered.
6. Using a billing agent whose compensation arrangement violates the reassignment rule.
7. Up-coding.
8. Un-bundling items or supplies.
9. Billing for new equipment but providing used equipment.
10. Continuing to bill for rental items after they are no longer medically necessary.
11. Re-submission of denied claims with different information in order to get paid.
12. Refusing to submit a claim to Medicare for which payment is made on a reasonable charge for fee schedule basis.
13. Inadequate management and oversight of contracted services, which results in improper billing.
14. Charge limitations.
15. Providing or billing excessive amounts of items or supplies.
16. Providing or billing for an item or service that does not meet the quality and standard of the DME item claimed.
17. Capped rentals.
18. Failure to monitor medical necessity on an on-going basis.
19. Delivering or billing for certain items or supplies prior to receiving a physician’s order or appropriate CMN.
20. Falsifying information on the claim form, CMN, or accompanying documentation.
21. Completing the treating physician’s or “other authorized people” portions of CMNs.
22. Altering medical records.
23. Manipulating the patient’s diagnosis in an attempt to receive improper payment.
24. Failing to maintain medical necessity documentation.
25. Inappropriate use of place of service codes.
26. Cover letters that encourage physicians to order medically unnecessary items or services.
27. Improper use of the ZX modifier.
28. Routine waiver of deductibles and coinsurance.
29. Providing incentives to actual or potential referral sources.
30. Compensation programs that offer incentives for items or services ordered and revenue generated.
31. Joint ventures between parties, one of whom can refer Medicare or Medicaid business to the other.
32. Billing for items or services stemming from a referral prohibited by the Stark physician self-referral law.
33. Improper telemarketing practices.
34. Improper patient solicitation activities and high-pressure marketing of non-covered or unnecessary services.
35. Co-location of DME items and supplies with the referral source.
36. Non-compliance with federal, state and private payer supplier standards.
37. Providing false information on the Medicare DME supplier enrollment form.
38. Not notifying the National Supplier Clearinghouse in a timely manner.
39. Misrepresentation of a person’s status as an agent or representative.
40. Knowing misuse of a supplier number, which results in improper billing.
41. Failing to meet individual payer requirements.
42. Performing tests on a beneficiary to establish medical necessity.
43. Failing to refund over-payments to a health care program.
44. Failing to refund over-payments to patients.
45. Improper billing due to lack of communication between supplier, physician, and patient.
46. Improper billing due to lack of communication between different departments of a provider.
47. Employing excluded people.