Columbia University College of Dental Medicine Billing Compliance Plan 2023-2025

Introduction

The student/resident providers, supervising faculty providers and administrative staff within the College of Dental Medicine (CDM) / Columbia University Health Care (CUHC) will comply with all Columbia University Irving Medical Center (CUIMC) policies and regulations as put forth in the “Columbia University Billing Compliance Manual, and the Columbia University Irving Medical Center Billing Compliance Plan”.

The student/resident providers, supervising faculty providers and administrative staff are committed to ensuring that all professional fee and CUHC Article 28 facility billing is conducted in compliance with applicable federal and state laws and regulations.  The CDM/CUHC Compliance Plan will be in agreement and compliance with the Columbia University’s Compliance Plan.

The provisions of this plan, applies to all faculty, residents, students, and staff involved in the billing of professional and/or CUHC facility services.  This plan applies to billing for all clinical activity for which the professional and CUHC facility revenues flow through University accounts or are subject to an academic assessment by the University, in essence all faculty with clinical teaching responsibilities.  The term “billing personnel” includes all University staff that assists or performs billing for clinical services.

The administrative responsibility for direction and implementation of the CDM/CUHC Billing Compliance Plan is assigned to the following compliance leaders:

Biana Roykh, DDS, MPH, Sr. Associate Dean for Clinical Affairs
Robert E. Armada, Sr. Director of Compliance for Clinical Finance and Operations

The Compliance Director coordinates compliance and related activities, in coordination with the CUIMC Chief Compliance Office, as well as, acts as liaison from the CUIMC Office for Billing Compliance to develop and disseminate educational and information materials, among other compliance related issues with the following CUHC sites:

  1. Vanderbilt Clinics
  2. Mobile Dental Vans
  3. Pediatric Dentistry Haven Clinic

All student/resident providers, supervising faculty providers and administrative staff with billing responsibility are initially screened prior to being hire and thereafter yearly by the University’s Office for Billing Compliance against the most current OIG Cumulative Sanctions Report and New York State Department of Health, and the Medicaid list of non-reimbursable providers, the GSA and OPMC websites.

Billing Guidelines and Activities
CUHC will bill only for professional services actually performed by a student/resident provider and/or supervised by a faculty approver as defined by the CUHC Rules and Regulations of the Professional Staff.  The supervising faculty provider is responsible for the approval of submission of accurate billing information, which must include; but, is not limited to the CDT procedural code(s), diagnosis codes, the date of service, and any additional pertinent claim information in accordance with the Physicians At Teaching Hospitals (PATH) regulations as set forth by the Centers for Medicare and Medicaid Services and New York State, DOH - Article 28 Diagnostic Treatment Regulations. The supervising faculty provider is responsible to ensure that all documentation in the dental record substantiates the service submitted for payment prior to submission of a claim.

Billing protocols are revised as needed and shared with all appropriate administrative staff and student/resident providers. The student/resident providers and supervising faculty approvers are responsible for following the policies and procedures associated with accurate and timely electronic record documentation. This includes adhering to insurance guidelines regarding covered services and entering accurate dental procedure coding on all accounts at the time of the visit. Administrative supervisory staff are responsible for tracking and monitoring the daily reports and following up on outstanding missing patient information accounts with student/resident providers and following up with supervising faculty providers for unapproved treatments.

The following information is required for billing:

  1. All resident/student providers must personally enter in the Electronic Health Record (EHR) the CDT procedure code which corresponds to each service that will be perform using the Treatment Plan Module with a status of “Planned”.
  2. All resident/student providers must write a note in the Electronic Health Record (EHR) documenting that services rendered are appropriate and medically necessary.
  3. Documentation in the Electronic Health Record (EHR) must be accurate and must clearly state the service rendered by the resident/student providers, the correct date of service and level of supervising faculty provider involvement in the case and presence. 
  4. Once the resident/student provider has completed the documentation in the Electronic Health Record (EHR), he/she must change the status of the procedure code from “Planned” to either “In-process” or “Complete”.
  5. Electronic Health Record (EHR) entries must be prompt and made as close to the time of service as possible, while the provider is able to recall the events and services accurately.
  6. The integrity of the Electronic Medical Records (EHR) must be protected.  Records may not be backdated for non-compliance reasons.  Any amendments or additions to the records must be for medically necessary reasons in the form of a signed addendum.  
  7. All resident/student providers must obtain the supervising faculty provider approval and sign off as close to the time of service as possible when they are performed and documented.

Physicians/Dentists At Teaching Hospitals

Because we are an academic medical center and train and educate, we are governed by the Federal Regulations concerning provider services in the teaching setting (42 C.F.R. 415, Subpart D).  The regulations, among other things, set forth the rules governing how a supervising faculty provider may bill Medicare/Medicaid for services where all or some part of the service has been rendered by a student/resident.  The regulations address the issues of necessary supervising faculty provider presence and medical record documentation needed to bill for professional services.  Under the regulations, in order for a supervising faculty provider to bill for his/her services where a student/resident has treated the patient and has already documented the services, the supervising faculty provider must be present and approve the student/resident’s documentation and billing code. 

All supervising faculty provider of service must adhere to the following billing requirements, as well as, Columbia University Irving Medical Center standards:

  • If a resident/student participates in a service, the teaching supervising faculty provider may not bill any insurance unless the teaching supervising faculty provider is present, or personally performs the service, for which payment is sought.
  • Supervision of patient clinical care provided by student(s)/resident(s) and maintains interaction with students on every patient seen and treated.
  • Supervising faculty provider assigned to care is responsible to review the documentation and billing code entry in the Electronic Health Record (EHR) by the student/resident upon completion of treatment.
  • If the Medical History have been changed or updated, the supervising faculty provider must review with student/resident and approve.
  • Timely approve/sign documentation and codes in the Electronic Health Record (EHR) immediately after each encounter, end of session (AM or PM) or the latest by the end of day prior to leaving.
    1. If for some reason supervising faculty provider cannot approve within the same day, the following will apply:
      1. Full time and Part time faculty will need to approve first thing following day when in clinic.
      2. Volunteer faculty will need to approve first thing next time they are schedule to be in clinic.
    2. If volunteer faculty will not be back within a reasonable time (due to leave or vacation), the Program Director should approve the documentation and code to prevent from the filing time limit to be exceeded.
  • Each and every service provided by a student/resident under the supervision of a faculty provider must have their participation and approval in order to drop a bill for the service performed.
  • All teaching supervising faculty providers must use their own billing provider/ NPI number; they may not use others’ numbers even when awaiting receipt of their own numbers.
  • Supervising faculty providers who fail to comply with the required approval guidelines will have their clinical privileges suspended and Epic access deactivated.

Credentialing

The College of Dental Medicine (CDM) / Columbia University Health Care (CUHC) conducts credentialing activities related to all licensed professional staff, accurately, and in compliance with Federal and State requirements and New York State DOH – Article 28 Diagnostic Treatment Regulations.

Any CUHC faculty whose credentials are not within the State regulations and standards will be suspended from clinical services and approving privileges in the EHR will be deactivated.

Billing Compliance Policies

The College of Dental Medicine (CDM) / Columbia University Health Care (CUHC), adheres to the compliance policies that appear in the Columbia University Billing Compliance Manual

Qualifications Standards for Compliance Personnel

All departmental compliance personnel must have a basic understanding of the following:

  • Medical Terminology
  • Documentation Standards
  • CDT coding
  • Diagnosis coding, including ICD-10 (when applicable)
  • EHR system used by the department for the documentation of dental services
  • Regulatory Compliance as set forth by:
    • The Centers for Medicare and Medicaid Services
    • New York State, DOH - Article 28 Diagnostic Treatment Regulations.
  • HIPAA Compliance for Privacy and Security

All departmental compliance personnel must demonstrate competence in these areas to the satisfaction of the departmental compliance leaders in conjunction with the CUIMC OFBC.

All compliance personnel must be provided with regular training and education opportunities both internal and external.

All compliance personnel have a dual reporting relationship to the CUIMC OFBC and the College of Dental Medicine.   Departmental compliance personnel are evaluated annually by the CUIMC OFBC using compliance best practices.

New Hires are subject to CUIMC OFBC approval.

The College of Dental Medicine will have compliance personnel appropriate to their size and complexity.  The College of Dental Medicine will ensure that compliance personnel are not involved in clinical practice, billing, revenue management, collections or other conflicts of interest.

Education and Training Sessions

Education and training sessions are held annually to ensure compliance with this plan. 

All newly appointed supervising faculty providers, residents, post-doctoral students, pre-doctoral students, billing personnel, and administrative staffs are required to complete a billing compliance session within thirty (30) days after hired date or engagement with CDM, but prior to obtaining access to the EHR.

All CDM supervising faculty providers, residents, post-doctoral students, pre-doctoral students, billing personnel and administrative staff must comply with the mandated annual compliance training session. Each employee is responsible for fulfilling his/her annual mandatory billing compliance training requirements. Any supervising faculty provider that will not comply and/or remains non-compliant, will be deactivated from the EHR and their privileges suspended.

The CUIMC Office for Billing Compliance (OFBC) education and training program mandates a one (1) hour of compliance education per year for all CDM/CUHC supervising faculty providers, student/resident, billing personnel and administrative staff, which can be met by training on specific coding and compliance issues on line or via a live seminar hosted by the CDM/CUHC Compliance Director, or new hire training sessions. 

Additional sessions are held as deemed necessary and appropriate by the Compliance Director for all who are involved in billing cycle, during each academic year regarding billing compliance and billing issues.  The attendance log for each session is maintained by the Compliance Director and a copy is made available to the CUIMC Office for Billing Compliance (OFBC).

An additional educational session can be scheduled based on the departmental or individual departments needs. 

As part of the compliance training, the following information is provided to all supervising faculty, residents, post-doctoral students, pre-doctoral students, billing personnel and administrative staff, which includes, but are not limited to:

  • The College of Dental Medicine Billing Compliance Plan
  • Medicaid Billing and Documentation Guidelines in accordance with Federal & State Laws
  • New York State DOH – Article 28 Diagnostic Treatment Regulations
  • Patient’s Bill of Rights
  • Medicaid “Essential” Dental Coverage, Exclusions & Non-Covered Services
  • Coding Examples – Most commonly used CDT codes
  • Health Care Fraud & Abuse Examples

Coding

The College of Dental Medicine supervising faculty and resident/student providers are responsible for choosing the CDT codes and diagnosis code for services billed and must be knowledgeable about the codes applicable to their practice. The supervising faculty providers are ultimately responsible for reviewing and approving the CDT codes related to services provided.

The CDM Compliance Department staff monitors whether the codes chosen by the providers match the medical record documentation to ensure compliance and that accurate codes are billed.

The CDM Compliance Department staff is responsible for notifying the Program Director and /or Section Chair when there is a possible discrepancy between the code chosen by the provider and the compliance staff’s determination of the appropriate code for the service. 

In no event should the Compliance Department staff change a code for service performed without informing the provider.

Monitoring and Auditing

The College of Dental Medicine and Columbia University Health Care (CUHC) have an ongoing commitment to ensuring that the audits are conducted in accordance with applicable laws and regulations and New York State DOH – Article 28 Diagnostic Treatment Regulations.  

Monitoring and auditing process is as follows:

  • The College of Dental Medicine compliance office will conduct retrospective random audits of services by Division/Program. 
  • Twenty-five (25) or more records will be reviewed for accuracy of procedure codes (CDT), as well as, medical record integrity.
  • The chosen services will be reviewed using compliance review standards set by the CUIMC Office for Billing Compliance and within the guidelines set by the Federal and State Laws, which includes, but not limited to:
    • Patient Identification
    • Conditions and reasons for which care is provided – Medical Necessity
    • Nature and extent of services provided
    • Type of services ordered for the recipient
    • Date of service
    • CDT code billed
    • Documentation of services rendered
    • Consents for Treatment / Surgical Procedures
    • Entering of notes in a timely manner
    • Faculty signature/approval
    • Interpretation Reports for all CBCT scans
  • Any discrepancies that are found will be marked off on the CDM Compliance Review Sheet, as to exactly what were the findings to be non-compliant, and serves as a platform for the educational tutorials given to the student/resident providers, supervising faculty providers and administrative staff.
  • Divisions/Programs with a compliance rate of 85% or greater for all services reviewed will be deemed compliant and will be re-audited during the next regular cycle.
  • Non-Compliant Audits (Round 1) – Divisions/Programs with a compliance rate of less than 85% for all services reviewed will have a written report shared with the Program Director and Section Chair, whose responsibility will be to ensure a corrective action plan is taken.  Students/resident providers will need to attend an education session (if deemed necessary by the Compliance Director), and be re-audited.
    • After the educational session, the student/resident provider’s services will be subject to another audit of services rendered in the sixty (60) day post-education session period. 
    • Another twenty-five (25) charges will be selected for review. If the student/resident providers achieve a compliance rate of 85% or greater for all services reviewed, he/she will be considered compliant and fall into the next regular cycle.
  • Non-Compliant Audits (Round 2) – Providers with a continued compliance rate of less than 85% will be subject to:
    • Additional educational sessions.
    • Suspension of billing (if necessary).
    • 100% billing review until they reach the acceptable compliance rate of 85% or greater for all services.
  • Once a compliance rate of 85% is reached, providers will not be subject to pre-billing review and be re-audited during the next regular cycle.
  • Continued Pre-Billing Review – Providers who remain on pre-billing review for an extended period will be counseled by the CDM/CUHC Billing Compliance Director and their Section Chair, Program Director.  Financial sanctions will be considered in the future to offset the cost of continued education and pre-billing review.

Corrective Action Plan

Whenever the conduct of any member of the faculty, student body, resident staff, billing personnel or administrative staff are considered to be inconsistent with the University’s Standards of Conduct or Standards of Professional Billing as defined in the Columbia University College of Dental Medicine Billing Compliance Plan, a request for corrective action may be made.  A request for corrective action will be in writing, and will set forth the facts upon which it is based.

Corrective action may include one or more of the following actions:

  • Issuance of a written warning or a letter of reprimand
  • Requirement of further training or in-service education, which may be at the individual’s expense
  • Imposition of terms of probation
  • A recommendation of the restriction, suspension or termination of appointment/employment

Compliance Reporting

All supervising faculty providers, residents, students, billing personnel and administrative staff are encouraged to communicate and discuss all issues affecting operational management and billing compliance. Compliance issues are to be directed to the CDM Compliance Leaders. They may also be directed to the CUIMC Office for Billing Compliance.

Supervising faculty providers, residents, students, billing personnel and administrative staff should report all compliance issues, concerns and questions to the CDM Compliance Director at (212) 305-9075. They may also utilize the University Billing Compliance hotline at (212) 305-7739 and/or the Columbia University - wide Compliance Hotline at (866) 627-3768 which the caller can remain totally anonymous.

Quality Assurance for Billing Activities

The CDM billing office conducts retrospective review of claims submitted to insurance carriers to ensure compliance with third party rules and regulations. 

It is the responsibility of the billing supervising faculty and other health care providers to ensure that appropriate documentation supports the charges submitted for payment.

Non-compliance issues will be reported to the Compliance Leaders.  The departmental leader concerned will be notified and educated to any non-compliance issue. 

The Compliance Leaders will report all problems or issues regarding non-compliance to the CUIMC Office for Billing Compliance for review, discussion and resolution. 

Collection of Health Insurance Copayments, Deductibles, and Coinsurance

Most health care insurance plans require customers to share the cost of the health insurance benefit.  Cost sharing is met through the imposition of health insurance deductibles, coinsurance, and copayments.  Each insurance company may implement varying dollar amounts for patient cost sharing, depending on the type of insurance and the premium paid for the insurance coverage. 

Routine or consistent waiver of the customer’s cost sharing is considered an abusive behavior by CMS, and may be seen as a violation of the individual health care insurance contract.  The waiver of deductibles and coinsurance may be constructed as a physician’s/dentist’s willingness to accept a lower reimbursement than the published fee schedule, which includes the patient’s cost sharing for the covered benefit.

Waiver of the professional fee is defined as no charge to the insurer and the patient for clinical services or items rendered.  This type of courtesy is acceptable as long as it is not related to referral patterns or illegal remuneration.  All insurance, including secondary insurance, should be billed and deductibles, coinsurance, and co-payments collected, with the exception of those services for which either the insurance or the patient is charged

The Office for Billing Compliance recommends:

  • All copayments, coinsurance, and deductibles must be collected, as far as reasonable, at the time of the service.
  • Dentist/physician practices will make at least one documented attempt to collect coinsurance, copayments, and deductibles.
  • The effort to collect deductibles, coinsurance, and copayments must be documented.
  • If these amounts remain non-collectable, the monies should be noted as non-collectable in the patient account record, and removed from the outstanding accounts receivable system.
  • Waivers of deductibles, coinsurance and copayments are acceptable only if collection presents a clear financial hardship for the patient.  Financial hardship is determined by financial need, not indigence, and may be based on assessing medical expenses as a percentage of income.  Patient financial hardship may also include Medicaid eligibility and employment status.

Professional and Employee Courtesy

The Office of Inspector General (OIG) model compliance plan for dentist/physician states that the routine waiver of deductibles, coinsurance, and copayments, for federal and commercial health care insurance programs is not permitted. 

Professional and employee courtesy, once common practice is no longer acceptable unless the entire fee is discounted, reduced, or waived.  The term “accepting insurance” or “accepting assignment” includes the collection of deductibles, coinsurance, and copayments.

All discounts and fee reductions extended as professional or employee courtesy must be in accordance with the policy and procedure, approved by the Program Director and documented in the patient’s chart in the “Notes”. All dentist/physician of care are expected to make a good faith effort to collect these payments for all clinical service charges submitted to all payers. 

HIPAA Training

All CUMC employees, students, and faculty providers are required to complete annual HIPAA training.  All research staff must also complete the Research HIPAA training posted on the Rascal database under the “Testing Center”. Contact information and instructions can be found at www.cumc.columbia.edu/hipaa .

HIPAA Compliance

It is the responsibility of the College of Dental Medicine to safeguard the privacy of all patients and to protect the confidentiality and security of patient information. 

To fulfill this responsibility and to comply with HIPAA (Health Insurance Portability and Accountability Act), CUIMC has implemented policies and standard procedures to protect the confidentiality and security of individually identifiable Protected Health Information (PHI) in all of its activities that require the access, use or disclosure of PHI.  These policies and procedures are posted on the HIPAA website available at www.cumc.columbia.edu/hipaa

Mandatory Reporting /Disclosure of Protected Health Information

Columbia University College of Dental Medicine / Columbia University Health Care, Inc. and its licensed healthcare providers, are required by law to report or provide Protected Health Information (“PHI”) to local, state or federal agencies or authorities without patient consent under certain circumstances, and respond to judicial or administrative requests for PHI under certain circumstances.  A copy of CUMC’s policy on disclosures of PHI for purposes of mandated reporting (required by law) can be found at http://cpmcnet.columbia/edu/hipaa/policies/required.html

Record Retention Policy

Patient medical records and related administrative and billing records shall be retained in their original or legally reproduced form for a period of at least six (6) years from the date of the last encounter or three (3) years after the patient’s age of majority, whichever is greater, unless otherwise required by any other university records retention policies or applicable statues, rules, or regulations. 

Medical records for patients who are mentally incompetent during any time they are treated shall be maintained for at least three (3) years after death.  These minimum periods for retention of patient medical records may be extended at the discretion of providers.  Patient medical records and related administrative and billing records should be properly discarded at the conclusion of the retention periods set forth in this policy.