COMING TO TERMS WITH COMPLIANCE

What does the word compliance mean to you as a practice manager? CLIA? OSHA? Far too many practice managers fail to realize the importance of Corporate Compliance and Billing and Reimbursement Compliance Programs. Perhaps, this is because these programs are voluntary unless the practice has had a previous violation.

By setting standards, educating staff and implementing internal controls, the smart practice declares its high standard and desire to abide by the laws and guidelines of the Federal government.

The Office of Inspector General a/k/a "OIG" encourages practices to implement voluntary compliance plans in order to further their fundamental mission of providing quality patient care and preventing fraud and abuse in the Federal health care programs.

As background, in 1996 HCFA, now known as CMS, implemented a plan to audit 20% of practices over a five-year period. HIPAA redefined "Fraud" as intentional deception or misrepresentation that an individual knows to be false and "Abuse" as incidents or practices of a provider that are inconsistent with accepted medical practices. Civil and criminal penalties were introduced. The program was extremely lucrative and the recoveries/findings staggering. As a result, many insurance companies followed suit and began auditing physician practices.

Through its efforts in the first half of fiscal year 2007, the OIG expected to recover $1.5 billion as a result of audits and $1.4 billion as a result of investigations. It excluded 1,278 individuals or entities guilty of fraud and/or abuse involving Federal health care programs
and prosecuted 209 criminal actions and 123 civil actions.

So what is involved in a compliance program?

Seven elements consisting of conducting internal monitoring and auditing, implementing compliance and practice standards, designating a compliance officer, conducting appropriate training and education for staff, responding to any detected offenses and taking corrective action, keeping the lines of communication open and enforcing the disciplinary standards as set forth in the compliance program.

Most practices already strive to abide by the rules and educate staff. So why not take a stand and make it official? The practice abiding by the law has nothing to fear. Yet, many great practices are not fully aware of all the rules and could be in violation of a few, or even one.

By incorporating the compliance plans, you show INTENT to do the right thing. Secondly, by following the compliance plan standards, you and your staff are educated on all guidelines and training material as set forth in the federal register. Should a practice find itself in a potential fraud/abuse situation or be involved in a chart audit, the compliance plan(s) will serve as an invaluable aid in its defense.

The OIG recently released its targets for 2008. It is important to remember that even though it releases new areas of focus, it doesn't mean the prior targets are not pursued.

Examples of new targets include services performed by Clinical Social Workers, Medicare payments for Psychiatric Services, the appropriateness of payments for physician services (including surgeries, consultations and home, office and institutional calls), the medical necessity and appropriateness of payments for polysomnography, the appropriateness of payments for physician services paid under Medicare Part B for patients in home health agencies or skilled nursing facilities, adherence to assignment rules, a review of services and billing patterns in geographical areas with high utilization of ultrasound services and a review of the extent to which Medicare physicians reassign their benefits to other entities.

Past targets (and not necessarily inactive) include the mandatory and correct usage of Advance Beneficiary Notices, usage of Modifier 25, the bypassing of bundled code edits with modifiers, overcoding of E&M services and incorrectly billing consultations when the visit was really a new patient visit.

I like to refer to the OIG as "the busy bees" and clearly, they are not going away. As a matter of fact, RAC (Recovery Audit Contractors) audits were introduced in California, New York and Florida in May 2005. RAC assists the OIG in their auditing efforts. It started as a pilot program but is now expected to be introduced in several new states due to the successful outcomes. Since the RAC auditors are paid based on a percentage of their recovery, may physicians view them as bounty hunters.

Incorporating the Corporate Compliance and Billing and Reimbursement Compliance Programs will not ensure a practice doesn't make mistakes, but it cam be a factor in the leniency of an auditor should a problem be discovered. No practice should be without them!

Kristine D. Eckis, President
Cellphone(863) 241-3494
bottomline2@aol.com