Dear Yale Medicine Colleagues:

A high percentage of the compliance violations that occur in healthcare settings are preventable. And most often, these incidents not intentional – they are due to a lack of awareness or education.

That’s why we created this newsletter, The Compliance Compass, and the YM Website (https://ym.care/compliance - please bookmark this link so you can easily find the site later). Both resources will help you stay up to date on state and federal laws and regulations and know how to identify risks and take the right steps to address or avoid them. They will also keep you informed about ways we’re supporting YM through education and training and how we’re aligning our compliance-related efforts with Yale University and across our academic health system.

The newsletter and the site also provide easy ways for you to share any compliance-related concerns and/or ask questions. From asking for clarification about a recent policy change to sharing the details about a questionable incident, we encourage you to reach out whenever needed. It’s always best to check – and we are here to help.

For your reference, the various ways you can contact us are below:

• YM Compliance Question form – send a question to the Compliance team.
• Yale Hotline at 1-877-360-YALE (9253)– report an issue anonymously.
• Yale University contacts – refer to this list to find out who to contact for specific compliance-related concerns.
• You can also contact me directly by sending an email to andrea.tenbrink@yale.edu.

Please review the updates below, watch for future updates, and check the YM site frequently.

I look forward to partnering with you in protecting YM, our patients, and each other in the future.

Sincerely,

Andrea TenBrink, MHA, CHC, CHPC
Senior Director, Yale Medicine Compliance

General compliance training upon hire and annually thereafter is a requirement for all health care compliance programs. YM has developed a training module that provides a general overview of the YM Compliance Program. On July 1, 2024, the training will be assigned to the entire YM workforce in Workday and will be required to be completed within 90 days. This includes Yale University employees who serve in any capacity that serves or works within the YM functions, including but not limited to administrative staff, clinical staff, faculty, and other clinical provider roles that bill for professional services. Please check Workday and complete the training within the required timeframe.

On July 1, 2024, all YM faculty and clinical billing providers (e.g., LCSW, CRNA, etc.) will also be assigned the YM Medical Billing Compliance training, which is due within six months (i.e., on or before Dec. 31, 2024). If you are within this group, you can choose to participate in the training in either of the following ways:

• Complete the Workday module. With this option, we encourage you to complete the module within 90 days to align with the YM Compliance Program requirement (for efficiency and ease, it may be helpful to complete the required trainings at the same time).
  
  
• Attend a pre-scheduled seminar or specialty-specific training for a department (at least six attendees) or an individual. Although you will have until Dec. 31, 2024 to complete either of these options, you will need to submit a request as soon as possible using the Yale Medicine Compliance Education Request Form. Doing so will allow time for scheduling and/or design.

A recent compliance audit within YM identified incorrect times associated with Inpatient/Observation E&M codes when utilizing a personally created time smartphrase.

Over the past two years, the CPT code time descriptor for inpatient and outpatient E&M services have been revised or changed. If providers are not fully aware of these changes and utilize their own personally created smartphrase to document E&M time, there is a risk for incorrect billing.

Compliance recommends utilizing the following smartphrase:

• TOTALMINUTES On the day of this patient’s encounter, a total of *** minutes was personally spent by me. This does not include any resident/fellow teaching time, or any time spent performing a procedural service.

For coding purposes, time for Evaluation & Management (E&M) services is the total time spent on the calendar date of the encounter for the same patient by the billing provider. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter. The provider needs to document the total time of the visit in their note with the associated details.

2024 Outpatient/Office Changes:

As of Jan. 1, 2024, outpatient E&M services no longer utilize time spans:

2023 Inpatient/Observation Timeframe Changes:

As of Jan. 1, 2023, the following inpatient/observation E&M timeframes were implemented:

• For the first time since the 1990s, the Office of Inspector General (OIG) is developing a series of compliance program documents, which offer guidance on the U.S. government’s structure and expectations for building and maintaining effective compliance programs. The first part of the series is the General Compliance Program Guide, which provides a wealth of information about the importance of compliance programs. The remaining series will focus on specific health care segments and should be announced over the next year. We will share the information as it becomes available.
  
  
• On Friday, April 26, 2024, the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) and the Centers for Medicare & Medicaid Services (CMS) issued a final rule under Section 1557 of the Affordable Care Act (ACA) advancing protections against discrimination in health care. YM compliance is currently working with the Yale Office of General Counsel to review the requirements and will share education and related policies and procedures soon.

• Policy is a core component of a compliance program as it outlines an organization’s rules and expectations for its employees. As part of a YSM-wide documentation management project, over the last two years, YM Compliance has implemented a process for the review and publication of documents within the PolicyTech solution. As this project expands, it will also update the YM Policies & Procedures (e.g., Practice Standards) as needed and establish a clear review process and governance structure. Additionally, a workgroup is forming to more closely align these documents across our academic health system and to ensure everyone across the University, YSM, and YNHHS can easily access them. We’ll continue to provide updates as this work continues.
  
  
• You can find specific policies, procedures, and bylaws on this page (please save it as a favorite!). If you have any questions about the YSM Policy and Procedure Program, contact Parami Hettiarachchi, senior policy analyst, at parami.mh@yale.edu.

• In response to your requests for additional coding and documentation education and support, we have created a new director of Compliance Education position. The role will partner with Revenue Cycle and the clinical departments to develop department-specific training and provide dedicated support to faculty. We are aiming to post and fill the role in the coming months. We’ll continue to keep you informed about our progress.
  
  
• Through an effort called the YSM Harmonized Learning Initiative, we are assessing the YSM Faculty and Clinical Billing Provider mandatory training curriculum across Yale University, YSM and Yale New Haven Health System (YNHHS). In addition to identifying ways to streamline learner access, this effort will reduce content duplication, make content updates, and address future required training needs. By ensuring the trainings are streamlined, effective, and efficient, we aim to reduce potential training fatigue and increase engagement.