Columbia University Medical Center - Billing Compliance Program
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Columbia University Billing Compliance Plan                         

Departmental Implementation Plans

Each clinical department shall appoint a faculty member and a Departmental Implementation Plans administrator to serve as the compliance leaders for departmental billing activities. The departmental compliance leaders will coordinate departmental compliance activities with the Chief Compliance Officer and the Director. There should be regular contact with the compliance leaders about matters of common interest. Department compliance leaders and department compliance staff report to both their department and to the Office of Billing Compliance on compliance matters.

Each clinical department must prepare a plan to address compliance efforts on a departmental basis. Large departments may also choose to develop plans for specific divisions. Before becoming effective, such plans should be reviewed by the Chief Compliance Officer to ensure consistency with overall policies. If there are concerns about the content of any departmental plan, the Chief Compliance Officer should consult with the Department Chair to explore whether the plan can be modified through mutual agreement. If such consultations fail to resolve the concerns, the Chief Compliance Officer may recommend that the Dean modify the department’s implementation plan.

The departmental (or divisional) implementation plans shall, at a minimum, include the following features:

  1. written policies and procedures for billing activities undertaken by departmental personnel;

  2. educational and training programs to address billing issues of particular importance to the department;

  3. a program for ensuring, and documenting, that all new department personnel, including faculty and housestaff, receive training with regard to proper billing;

  4. a program for routine "spot checks" of departmental billing to review compliance, with the results of such reviews being reported to the department’s compliance leader and to the Director of Compliance;

  5. a system that tracks billing or compliance issues that have been raised within the Department and the resolution of those issues, reporting to the Office of Billing Compliance;

  6. the use of compliance as an element in evaluating the performance of managers and supervisors who have responsibility for billing;

  7. an annual review of the existing compliance plan in order to identify the need for changes and to identify specific compliance objectives during the succeeding year; and

  8. a program for developing corrective action plans whenever compliance issues are identified.

Departments or Divisions must have the advance review and approval of the Chief Compliance Officer prior to engaging any outside billing consultant or other entities involved in billing, coding, collections or related activities and must provide a copy of any reports prepared by such consultants or other entities. Departments, Divisions and individuals covered by this Plan must promptly report all contacts by government agencies and other third parties concerning billing matters to the Chief Compliance Officer. Any person covered by this Plan who is or becomes the subject of a proceeding which could result in exclusion from Medicare or other government programs must promptly disclose that information to the Chief Compliance Officer.

Columbia University Billing Compliance Plan
September 9, 1996 (with amendments to October 2003)

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