|Title: Quality Assurance Monitoring|
STATEMENT OF PURPOSE
The objective of the monitoring standard is to ensure that all procedural and diagnosis code assignment, supervision requirements, medical record supporting documentation and fee abstraction performed by USC Care Medical Group, Inc., and its physicians conform to the USC Compliance Standards & Procedures. This is accomplished through regular monitoring as defined in USC Healthcare Compliance Standard MA-500.
This is a companion standard that will address providers who have previously satisfied reappointment requirements in the past, yet fail their first round monitoring in subsequent reviews.
USC Providers shall bill according to applicable USC Healthcare Compliance standards, laws and regulations governing the reimbursement of medical services.
USC Care Medical Group is responsible for ensuring that providers satisfy the requirements defined in the Compliance Program.
The USC Healthcare Compliance Office is responsible for developing USC’s billing compliance program which includes billing monitoring. In the event a provider who has been through the reappointment process fails monitoring subsequent to reappointment, the Office of Culture, Ethics and Compliance will conduct a supplement review of billing records.
The following procedural steps shall be followed to monitor the faculty and non-physician providers that have failed monitoring subsequent to reappointment.
- Providers who have failed monitoring subsequent to reappointment are required to complete the monitoring process according to USC HealthCare Compliance Standard MA-500.
- Additionally, these providers will be scheduled for a supplemental review between reappointments. The supplemental review will not replace monitoring activity for upcoming re-appointments.
- The Office of Culture, Ethics and Compliance will coordinate with the Clinical Department for a review of randomly selected encounters which are representative of the errors found in the most recent monitoring.
- The Office of Culture, Ethics and Compliance may develop and employ various monitoring techniques custom tailored to address identified issues for individual practitioners.
- At the conclusion of supplemental review, the provider will be scheduled for an education session with the USC Compliance Coder/Educator.
- Upon the second supplemental failure, the provider will receive a subsequent follow-up review within 30 days.
- If the subsequent second review identifies instances of non-compliance, the provider will be placed on a Concurrent review.
- The Office of Culture, Ethics and Compliance has the authority to suspend billing activity of any provider, as the situation warrants, until the provider demonstrates proficiency in the deficient areas identified at the time of monitoring.
- If a provider demonstrates a significant rate of non-compliance or a consistent pattern of errors, as determined by the USC Office of Culture, Ethics and Compliance, the USC Office of Culture, Ethics and Compliance may require, at the Clinical Department’s expense, a more focused record review and participation in additional education and training sessions (i.e., either an increase in the number of encounters reviewed or the frequency of the quality assurance review).
- The USC Office of Culture, Ethics and Compliance in conjunction with USC Care Medical Group and the Office of the General Counsel may require other remedial action steps depending upon the severity and frequency of the errors.
Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Help & Reporting Line at (213) 740-2500 or (800) 348-7454.