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Currents Medical Center employees are reminded that all employees involved in rendering care and preparation of claims must fulfill the requirement to complete compliance training, as mandated by the federal Office of the Inspector General (OIG) of the Department of Health and Human Services. This mandated training includes two hours of general compliance training due to be completed on or before June 19, and two hours of billing training due on or before Oct. 2. Failure to fulfill this requirement will result in costly penalties to the Medical Center. Managers and directors must ensure that all concerned employees are given timely notice of this requirement and the training schedule. Regretfully, individuals who fail to complete the training in a timely fashion will be subject to disciplinary measures for failure to comply with the compliance program requirements. We need everyone’s understanding and cooperation. Additional information is outlined below, including the updated training schedule.  Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center Patient/customer grievance process reviewed Lee Budd, risk manager, reviewed changes and enhancements to the new patient/customer grievance process. The revised policy is available on the MUSC web site. Stephanie Davis recently distributed an e-mail to managers and directors that explained how to access revised policies on the MUSC web site. Paid Time Off/Leave Conversion or “Pay Out” Option The Medical University Hospital Authority implementation is planned for July. Medical Center employees’ leave will convert to a new Paid Time Off (PTO) plan. No one will be required to lose any accrued annual or sick leave, because all accrued leave can convert to the new PTO plan. Unused holidays can be carried over until used within one year. Employees who do not wish to convert their annual leave to PTO may be paid for their annual leave, but their sick leave will be forfeited. The “pay out” of annual leave is not recommended, but this will be a personal decision. (This annual leave “pay out” option at the time of the Authority implementation should not be confused with the PTO cash-in provision, planned beginning in July 2001, as outlined in the PTO policy.)  The form to be used for annual leave “pay out” will be disseminated to departments in the near future, along with instructions to employees for the form completion and return date. Compliance Training Managers and directors are reminded that “all clinical personnel who render medical services and personnel involved in the generation, preparation or submission (including documentation) of claims on behalf of MUSC” must complete two hours of general compliance training by June 19 and two hours of preparation of claims (“billing”) training (to include clinical employees such as nurses) by Oct. 2. Following is a recap of questions and answers, which for the most part have previously been disseminated through e-mail by the Medical Center Compliance Office. This information should promote understanding. 1) Who must complete the training?  According to the Institutional Compliance Agreement “All MUSC clinical personnel who render medical services as employees of MUSC ... any individual who is involved in the generation, preparation or submission [including documentation] of claims on behalf of MUSC.” This includes clinical staff (nurses, techs, therapists, etc.) who document in a patient chart, employees who complete charge tickets or test requests, use pyxis, register patients, code procedures or diagnoses, submit bills or work with the charge master. 2) How much training is required? All individuals who meet the criteria outlined above are required to receive four hours of training including two hours of general compliance training and two hours of billing training. 3) How do we get this training?  The best way to get the general compliance training is to attend a 1.5 hour general compliance training session, and complete the compliance module in DeMedici, for which you will receive 30 minutes of training. This will give you the required two hours of general compliance training. Much of this training is being done by the individual departments. There is also training available through the Compliance Office. The training schedule below lists some of the opportunities to get this training. (This list also indicates several opportunities to attend billing training. Future updates will list additional opportunities to attend billing training.) 4) When is this training to be completed?  The two hours of general compliance training is due on or before June 19. The two hours of billing training is due on or before Oct. 2. 5) What about the code of conduct? Each employee received a code of conduct in 1998 through compliance training and signed a sheet entitled “Documentation of Compliance Program Education;” or if hired after March 1998, each employee should have a signed “Orientation/Competency Checklist and Test.” Either of these documents proves that an employee has received a code of conduct. Managers must verify that each employee has one of these two certifications in his/her departmental personnel file. 6) What format should be used if the manager plans to conduct the general compliance training for his/her department? The Compliance Office will provide the presentation format, which can be presented by using PowerPoint or slides. Call Beth Bair at 792-6169 for this information. 7) If a manager plans to conduct billing training in his/her department, what must be covered? The OIG requires that the following six criteria be covered in order to receive credit for billing training: A.  Submission of accurate requests for reimbursement B.  Documentation of medical records C.  Accuracy of any documentation D.  Reimbursement regulations E.  Legal sanctions for improper claims submission F.  Examples of proper and improper billing practices If managers provide billing training in their department, they must provide the Medical Center Compliance Office with the agenda so it can be on file in the event of an OIG inspection. 8) What about non-Medical Center employees who render services “on behalf of MUSC?” Even if they are not Medical Center employees, individuals who take part in any of the activities listed previously are required by the OIG to get this training. If managers have individuals who are not employed by the Medical Center, but do take part in the clinical or billing processes, they should inform the Medical Center Compliance Office of their names, job titles, and who employs them. 9) What about UMA employees? UMA employees have different training standards they are required to meet and will receive this training based on the UMA’s compliance agreement. Managers do not need to notify the Compliance Office of these individuals. 10) What about new employees? New employees who meet the definition given above must receive both the general compliance and billing training within 30 days of hire. The general Medical Center orientation will count as the two hours of general compliance training. The two hours of billing training will be met in a variety of ways. Those individuals who attend clinical orientation will be given the billing training requirement.  Other departments, such as Hospital Patient Accounting and Medical Records, have formal departmental orientations that will count as their two hours of training. Managers in other areas need to provide the Medical Center Compliance Office with documentation from their departmental orientation so it can be approved to meet this requirement.  11) How should training be documented? Each manager has received a roster of his or her employees. (Many have made the necessary corrections and notified the Compliance Office of these corrections.) This roster is in Excel and can be formatted to keep track of employees who have received training. When the department provides a training session to employees, a sign-in sheet must be kept. The manager must keep up with who is receiving training to ensure each employee has received the required four hours of training. The manager will turn this roster in to the Compliance Office by the deadline. Managers should make a copy of any sign-in sheets from departmental training sessions and forward them to the Compliance Office as well. 12) How will managers know when one of their employees receives training at a session conducted by the Compliance Office? Each week, the Compliance Office will monitor which employees receive training at each of the sessions sponsored by the Compliance Office. The Monday following that week, the Compliance Office will send managers an Excel file that is sorted by cost center, letting them know which of their employees attended one of these sessions and how much time credit they should receive. Managers will be able to take this information and add it to their training roster. 13) Are there other ways to get training? The Compliance Office has recently made a video tape of the general session. Copies are available in the Compliance Office.  14) What happens if someone fails to complete the required training? Hopefully, everyone will understand the importance of this training and the costly penalties that will be imposed upon the Medical Center if training is not completed by all concerned employees in a timely and well documented manner. Employees who fail to complete the general compliance training by June 19 will be subject to disciplinary action in accordance with the progressive discipline policy; i.e., failure to complete training by June 19 results in a written reprimand. Following a written reprimand, failure to complete general compliance training by July 3 will result in a suspension (or the disciplinary action could be more severe for someone already in the progressive discipline process for other problems). Compliance Training Schedule May 23, 24  and 31, “General Compliance” Reeece Smith, 2:30 - 4 p.m.  Storm Eye Institute. All invited 25 “Pyxis” Melody Branham, 10 - 11a.m. Storm Eye Institute. All invited 28 “General Compliance” Reece Smith, 3 - 4:30 p.m. IOP Auditorium; May 30, 9 - 10:30 a.m. Storm Eye Institute. All invited June 1  “General Compliance” Reece Smith, 2:30 - 4 p.m. Storm Eye Institute. All invited 6 “Resp Therapy Billing” Karen Northcutt, 7:30 - 8:30 a.m. Place to be determined. RT invited; June 6 “Basic Billing” Karen Northcutt, 9:30 - 10:30 a.m. Storm Eye Institute. All invited; June 6 “Lab Billing” Karen Northcutt, 10:45 - 11:45 a.m. Lab Conference Room. Lab Managers; June 6 “Rehab Billing” Karen Northcutt, 12:15  - 1:15 p.m. Place to be determined. PT, OT, ST 7 “Cardio & Rad Billing” Karen Northcutt, 1 - 2 p.m. Rad Conference Room. Card and Rad; June 7 “Medical Records” Karen Northcutt, 3 - 4 p.m. Storm Eye Institute. Medical Records; June 7 “ER Billing” Karen Northcutt, 8 - 9 a.m. ED Conference Room. ER; June 7 “Ambulance Billing” Karen Northcutt, 11 a.m. - noon. MEDUCARE, Ambulance 8 “Pharmacy Billing” Karen Northcutt, 7 - 8 a.m. Place to be determined. Pharmacy 12 “General Compliance” Reece Smith, 8:30 - 10 a.m.; June 13, 9:30 - 11 a.m.; June 14, 2:30 - 4 p.m. Storm Eye Institute. All invited For additional information, contact either Reece Smith, compliance officer, at 792-6128, or Beth Bair, compliance coordinator, at 792-6169.