Compliance Checking Understanding and Using SAM’s Compliance Checking

Introduction This presentation will show you how to enter compliance rules into SAM and troubleshoot out- of-compliant visits. After this presentation you should be able to use the three levels of compliance checking (payer set dates, insurance authorizations, and doctor orders).

Compliance Checking Topics 1. Entering payer set dates 2. Entering insurance authorization compliance rules 3. Entering doctor order compliance rules 4. How SAM checks scheduled visits for compliance 5. When SAM checks for compliance 6. The compliance summary screen 7. Troubleshooting out-of-compliance schedules 8. How to turn compliance checking on and off 9. The Compliance Summary Report 10. The Expiring Compliance Rules Report

Entering payer set dates

Entering payer set dates (cont.) 1. On the “Edit Client/Payer” screen, enter the dates for which the payer will pay for the client’s services. 2. When new authorizations are received, extend the authorization end date – LEAVE THE START DATE ALONE. If you move the start date into the future, you will probably cause historic visits to become “out-of- compliance”

Entering Insurance Authorization Compliance Rules On the “Edit Client/Payer” screen, click the “Ins Auth” button.

Insurance Authorization Compliance Rules (cont.) The “Edit Compliance Rules” screen will appear.

Insurance Authorization Compliance Rules (cont.) 1. The client, payer, and rule type are defaulted for you. 2. Click the new button. 3. Enter an Authorization Number if applicable. This Authorization Number will be printed on the UB92 claim and may be optionally printed on the visit report. 4. Choose the skill/sub-skill, frequency, duration, and interval to represent the payer authorization. 5. Enter the start and end dates of the rule. If the duration goes past the end date, the end date will be used as the last date of the order. 6. Optionally enter a comment. 7. Save and exit. 8. A compliance rule will check against all visits within its date range that have a matching client-payer-skill. 9. Note – Rules for a particular sub-skill will only look at visits with the sub-skill. 10. Any rule that is older than 1 year (based on the end date) will be purged when the system reindexes at night unless you add a line to your n:\sam.ini file: Ini_Comp_Rules_Purge_Months,x (where x is the number of months back you wish to retain your compliance rules)

Entering doctor order compliance rules From the “Edit Patient” screen in Care Manager, click the “Define Plan of Care/Verbal Order” button.

Entering doctor order compliance rules (cont.) From any plan of care or verbal order, click the “Compliance Rules” button.

Entering doctor order compliance rules (cont.)

1. The “Edit Compliance Rules” screen will appear. 2. The client, payer, and rule type are defaulted for you from the selected plan-of- care/verbal order. Note that Doctor Order compliance rules are not tied to individual plans-of-care, rather they are tied to the client and payer provided by the plan of care. 3. Click the new button and choose the skill/sub-skill, frequency, duration, interval, start and end date to represent the doctor’s order. 4. The end date snaps to the end of the Medicare week if the unit frequency is by the week. Unlike insurance authorizations, if the unit frequency of a doctor order is by week, visits are checked according to Medicare’s week. (Medicare’s week is defined by your agencies end of the week. This is entered on SAM’s Define Office screen in System Manager). 5. Optionally enter a comment – for instance, the doctor’s name and office location if entered from a different plan of care. 6. Save and exit. 7. Any rule that is older than 1 year (based on the end date) will be purged when the system reindexes at night unless you add a line to your n:\sam.ini file: Ini_Comp_Rules_Purge_Months,x (where x is the number of months back you wish to retain your compliance rules)

Overlapping compliance rules If the newly added compliance rule’s dates (either doctor order or insurance authorization) overlap another compliance rule for the same payer-skill, the overlap screen will appear.

Overlapping compliance rules (cont.) 1. If the newly entered rule represents additional services (on top of what is currently ordered), choose the “Save New Rule as Addition to Existing Rules”. This will not adjust any dates on existing rules and will treat the new rule as “Additional” orders. 2. If the newly entered rule represents countermanding orders (orders that replace what is currently ordered), choose the “Save New Rule as Replacement for Existing Rules”. This will cause the dates of other orders to be changed so that no overlap exists.

How SAM checks for compliance 1. Any visit associated with a client and payer that is outside of the client-payers authorization date range will be marked in the schedule as out-of- compliance. This means the visit will turn black on the schedule. 2. Beyond payer authorization date checking, if insurance authorization rules or doctor order compliance rules exist for visit’s client-payer-skill, each visit not covered by a rule will be marked out-of-compliance on the schedule. 3. If a rule authorized more visits than are scheduled, the compliance summary screen will show how many more visits are authorized under the rule. 4. The compliance summary screen will also list all out-of-compliance visits. 5. Visits for a client-payer-skill/sub-skill are only checked for compliance if there is a related rule. Visits occurring before the start date of the first rule are not checked for compliance – they are considered in-compliance. 6. If you have created rules for a client that include a rule for the skill level and the sub-skill level, it is important to note that the rule at the sub-skill level will be used first and then the rule at the skill level will be used. For example: If you have a rule for a LPN 3 visits a week and a rule for a LPN-HighTech 3 visits a week. If schedule 4 LPN-HighTech visits in a week and only 2 LPN visits in the same week, all visits are in compliance because the 4 th LPN- HighTech visit was compliant under the LPN rule. We typically recommend that rules either be entered at the skill level OR at the sub-skill level.

When SAM checks for compliance 1. When payer set dates are changed 2. When you right click on a visit and select the compliance menu item 3. When a visit is added, moved, or edited either manually or with the copy or update visit wizards. 4. When the Compliance Report is run.

The compliance summary screen Right-click a visit to display the visit menu. Select the compliance option to run compliance checking for the current client’s schedule and display the Compliance Summary screen.

The compliance summary screen 1. The top window on this screen shows “Compliance Rule Deficits”. The information in this window represents doctor orders or insurance authorizations which do not have enough visits scheduled to satisfy the rule. The left column will display “D” for doctor order or “I” for Insurance Authorization. SAM divides each rule into one line for each frequency unit (for instance a week) and shows how many total visits are scheduled to meet the rule, how many visits are needed to meet the minimum requirements of the rule, and how many more visits may be scheduled before the upper limit of the rule is violated. 2. The bottom window lists all visits that are out-of- compliance.

The compliance summary screen (cont.) 1. Each row in the “Visits Out-Of-Compliance” window shows the out-of-compliance reason as either “Payer Set Dates”, “Ins Auth”, or “Dr Order”. 2. If a visit is out-of-compliance for all three, the visit will show out-of-compliance due to payer set dates. If a visit is out- of-compliance for both insurance authorizations and doctor orders, the visit will show out-of-compliance due to insurance authorizations. If a visit is only out-of- compliance with doctor orders, it will show out-of- compliance due to doctor orders.

Troubleshooting out-of- compliance schedules Use the “Rules” button on the scheduling screen to display the “Compliance Rules” screen. This show the rules effecting the visits displayed on the current schedule. Clicking the “Show All Rules” box will cause historic rules to be displayed.

Troubleshooting out-of-compliance schedules 1. Right-click on a visit to run compliance checking and study the resulting Compliance Summary screen. 2. Use the “Prefs” button on the scheduling screen to display visit compliance status. (This will indicate that visits are out-of- compliance due to either payer set dates, insurance authorizations, or doctor orders.) If a visit is out-of-compliance for all three, the visit will show out of compliance due to payer set dates. If a visit is out of compliance for both insurance authorizations and doctor orders, the visit will show out-of-compliance due to insurance authorizations. If a visit is only out of compliance with doctor orders, it will show out-of- compliance due to doctor orders. 3. Edit, Delete, or add doctor order and insurance authorization rules as needed to reflect what has been actually ordered and authorized. Run compliance checking after changing any rule.

1. The Compliance Summary Report will report all out-of-compliant visits across all clients as well as compliance rules with service deficits. This report shows current compliance values as a result of compliance checking done within each client’s schedule. 2. When run in the front office, this report will run compliance checking against all matching clients, update the compliance values on any visit needed, and optionally generate two reports – a Compliance Deficit Report and a Visit Compliance Report. 3. When run at the back office, although both reports are generated, the compliance values on the visits are not updated. They are not updated because this would cause the updated visit to data exchange to the front office, possibly overwriting work done on the visit by the front office. Compliance Summary Report

Compliance Summary Report (cont.) You choose the date range of the visits and rules you want to see and the group of clients for which compliance should be run by their status and payer. Compliance for all matching clients in the current office will checked.

Expiring Compliance Rules Report This report may be used to determine when your compliance rules (you choose what type to report) will be expiring. Simply enter a time-frame, optionally select the client’s status and/or payer and compliance rule types and SAM will report what rules will be expiring in the selected time-frame.

How to turn compliance checking on and off. 1. On any client’s schedule, from the schedule menu, selected the “Show Compliance” option to toggle compliance checking on and off.

Summary Compliance checking is a tool SAM provides to aid you in keeping your services within doctors orders and within financial authorizations. If you have ideas about how compliance checking can be more useful to your organization, us your suggestion at