Frequently Asked Questions

Q1. What organization oversees Medicare and Medicaid at the federal level?
A1. Center for Medicare and Medicaid Services (CMS)

Q2. Who is the Chief Compliance Officer for the SOM?
A2. Peter Cadwell

Q3. Who is the Health Care Compliance Officer for the SOM?
A3. Angela Blunk

Q4. Who is responsible for the compliance program at SOM and SIU P&S?
A4. The SOM has established an Office of Compliance under the Office of the Dean and Provost. The SIU P&S Compliance Office shall work in close cooperation with the SOM Office of Compliance, in the development and enforcement of policies, procedures and guidelines related to compliance issues.

Q5. How do I find out when my department is scheduled for its annual chart review?
A5. The attached link provides the schedule for annual chart reviews.

Q6. How do I know if I failed a review?
A6. All reviews are scored by a point system developed by the Office of Compliance. A letter will be sent to the provider notifying them that they received a failing score on their review. The Office of Compliance will schedule a meeting with the provider to go over the results of the review and to answer any questions.

Q7. Does the Office of Compliance change the codes during an annual chart review?
A7. The Office of Compliance does not change the codes of providers based upon their annual review until either: (1) the provider returns the Acknowledgment of Review letter to the Office of Compliance; or (2) 14 days have passed since the date of the letter informing the provider of the annual review results has been sent.

Q8. Who is required to go to annual compliance training?
A8. All SIU P&S Members/Employees, medical residents and clinical/departmental personnel will be required to attend an annual education and training session. The education and training session includes a review of the written compliance policies and procedures. Training may be a live session or in a web-based format. Annual sessions will be announced as soon as possible for planning purposes.

Q9. Why does the University and SIU P&S conduct reviews of providers’ charts?
A9. The University Office of Compliance and the SIU P&S Compliance Office conducts internal reviews of billings submitted for reimbursement under Medicare and Medicaid or other government programs by SIU P&S members/providers in order to ensure adherence to applicable regulations and guidelines. External expertise may be brought under contract to assist the in meeting this objective.

Q10. Why do we need a compliance program?
A10. The Federal Government has stressed that it is focusing on eliminating fraud and abuse in the health care arena.  Compliance programs are a way to combat fraud and abuse.  The existence of a compliance program is considered by the federal government when determining the level of sanctions and penalties if a provider is found to have violated the fraud and abuse laws.

Q11. What is the goal of the compliance program?
The goal of the compliance program is to eliminate the coding and billing errors that will reduce the risk of fraud and abuse as well as is to provide a resource for providers and staff to be alerted to potential problems through education.

Q12. Why do we need a compliance program for payers other than Medicare and Medicaid?
Although claims to commercial insurance carriers are not as at high of risk for fraud and abuse as Medicare and Medicaid, the failure to bill correctly and failure to provide appropriate documentation can result in civil claims by insurance carriers of fraud.

Q13. Why can't I just undercode all my services?
Some providers have decided to play it safe and undercode all Medicare cases.  However, undercoding is a problem because it decreases earned revenue and creates false utilization patterns.  As a result, a provider can be identified as an outlier which could result in an investigation by federal authorities.

Q14. What is incident-to billing?
Incident-to billing is any billing that is provided incident-to the physician's services by the physician's axillary personnel.  In order to bill for incident-to services the following requirements must be met:

1. Written orders for subsequent services by ordering physician
2. Axillary personnel must be employed by the ordering physician;
3. Physician (Supervising Physician) must be in the clinic (on the same linoleum) on the day the incident-to services are being provided and is providing supervision to the axillary personnel.

Q15. When the supervising physician is different from the treating physician, how should the incident-to service be billed?
The service should be billed under the provider number of the physician who supervised the axillary staff.

Q16. Does a supervising physician have to be in the clinic in a Rural Health and County Clinic?
No, the supervising physician need only to be accessible by phone and able to come to the clinic in a reasonable period of time.

Q17. What is a consultation?
A consultation is a service provided by a physician whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician.

Q18. What is the difference between a consultation and a new patient visit?
If the requesting physician is asking for a transfer of complete care of the patient, then the visit should be coded as a new patient visit and not a consult.

Q19. Is it legal to submit a claim to Medicare for an off-label drug?
Submitting a claim to Medicare that includes a charge for an unapproved use of an "off-label" drug increases your risk of being in noncompliance with Medicare regulations issued by the Centers for Medicare and Medicaid Services (CMS) and by the U.S. Food and Drug Administration (FDA).  The reason: If the charge does not meet the medical necessity standards, the government could construe it as a violation of the False Claims Act.

Q20. What is CERT?
CERT, Comprehensive Error Rate Testing, is a program designed for calculating a national error rate for Medicare claims being implemented by the Center for Medicare and Medicaid Services (CMS).  This is done by requesting medical record information directly from providers.  The medical records are evaluated by CERT staff to determine the correct outcome of a claims.  The most recent analysis of the CERT findings has shown significant error patterns.  If errors are found during a CERT review, CMS will collect the over payments.
For more information click on site:

Q21. What to do if I receive a CERT request?
A request for a CERT review will come with either an initial request via letter or telephone.  If a request comes via letter, the request will include a list that identifies beneficiaries and the medical records/claims, as well as instructions on where to mail the request.  If you receive a CERT request please forward it to Cheryl McGill in the Billing Department.  If a request via telephone, please direct the phone call to Cheryl McGill in the Billing Department.