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Compliance Programs Critical Safeguard


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From complex coding requirements to strict patient referral rules, physicians are scrambling to avoid entanglements in a broad net of federal, state, and commercial payer requirements. Get ideas on how you can help protect your practice.

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Compliance Programs Critical Safeguard

  1. 1. Compliance ProgramsA Critical Safeguard forPhysician GroupsBy Bess Ann Bredemeyer, BSN, RN, CHC, CPC, PCS Practicing medicine has become increasingly difficult for many physicians, thanks to an ever-expanding web of healthcare rules and regulations. From complex coding requirements to strict patient referral rules, physicians are scrambling to avoid entanglement in a broad net of federal, state and commercial payor requirements.The stakes are high. Federal law Comprehensive Complianceenforcement efforts have become Programsmore aggressive as the volume of To protect themselves in thisrules has increased. Highly publicized unforgiving environment, a growingcases involving fraud – along with number of physician groups aresoaring healthcare costs – have fueled creating comprehensive compliancesuspicions from both regulators programs. These programs help ensureand the public about the intentions an organizational commitment toand integrity of many provider compliance while offering a systematicorganizations. means for monitoring, understanding and complying with specific rules andFor those organizations found to have regulations.intentionally violated the law, thepenalties can be catastrophic. Large Compliance programs have thefines, exclusion from participation in added benefit of mitigating fines andstate and federal insurance programs penalties if a violation is found by aand even prison time all are potential regulatory agency. When a violationremedies for mistakes the government is identified, regulators generally aredeems to be fraudulent in nature. more willing to give the offending organization the benefit of the doubt if a compliance program already is in place and operational. 1
  2. 2. Moreover, by helping ensure the Services (CMS). OIG enforcement are frequently most familiar withsubmission of clean and timely claims, efforts are conducted through audits, regulations affecting coding, billinga well-designed compliance program investigations and inspections. and reimbursement.can speed payment and reduce billingerrors and denials. In today’s climate As part of its mission, the OIG Identifying the Risksof flat or falling reimbursements, publishes guidelines for establishing With leadership in place, the next taskoptimizing revenues arguably is just voluntary compliance programs is to identify and prioritize risks facingas critical for physicians as reducing for different kinds of healthcare the organization. For physician groups,regulatory exposure. organizations. These guidelines offer a areas of highest risk typically include framework for creating a program that coding and billing, reasonable andMany physician groups that rely on incorporates elements the OIG deems necessary services, documentation andan outsourced vendor for their billing essential. In late 2000, for example, improper inducements, kickbacks andservices erroneously believe the the OIG published OIG Compliance self-referrals.vendor’s compliance plan fully protects Program for Individual and Smalland indemnifies the practice against Group Practices. One of the best ways to define risk isregulatory problems. Although the to become familiar with the currentvendor’s program may serve as an Although some compliance specifics activities, plans and policies of theimportant safeguard, in the eyes of will differ depending on the physician’s HHS OIG. Each fall, the OIG publishesregulators, it is no substitute for a plan specialty and the organization’s areas a document called the Work Plan. Thethat is designed and managed by the of highest risk, the guidelines offer Work Plan provides a detailed roadmapgroup. an ideal introduction to the overall of the areas and topics the OIG will be subject and detailed suggestions for focusing its enforcement efforts on inMaking the Commitment creating an effective program. The the coming fiscal year. The document isIt is important to remember that model compliance programs cancreating a viable compliance program found at a commitment of both time complianceguidance.html.and resources, whether the initiative isdeveloped internally or with the helpof an outside expert. Essential Program ElementsThis commitment must be sustained Designating a Leaderonce the program is completed to One of the first steps in creatingensure effective implementation a viable compliance program is toand genuine buy-in throughout the designate an individual who will haveorganization. A plan that looks perfect primary responsibility for overseeingon paper but gathers dust on a shelf the creation, implementation andis hardly worth the effort required to operation of the initiative. Thiscreate it. In fact, it can be counter- person may be a physician with anproductive. Federal investigators take interest in compliance or perhaps ana dim view of inactive compliance office manager. Whoever is selected, organized by type of healthcare serviceprograms, since regulators may the person should be trustworthy, and offers a wealth of informationlogically assume that the plan was respected and have enough authority about the specific kinds of regulatorycreated for show only. In addition, they to ensure proper implementation and scrutiny provider organizations canwill hold an organization accountable execution of the program. expect. A careful reading of the Workto its own standards, even if those Plan will give compliance directorsstandards are not operational and Those who should not be considered for compliance leadership are invaluable insight regarding aspects ofeven if they exceed the government’s their practice that may attract scrutinyrequirements. individuals who are intimately involved in the financial aspects of the practice. in the months ahead. The Work Plan While these persons may have the can be found at Compliance Guidelines necessary skills, the perception of publications.html.A useful place to begin whendeveloping a compliance program is a conflict inevitably will arise if the Another way to evaluate for potentialwith the guidance published by the same individual or department is risks and staying abreast of industryDepartment of Health and Human responsible for both reimbursements activities that may potentially affectServices’ Office of Inspector General and regulatory compliance. your practice is to read advisory(OIG). The OIG is responsible for opinions published by the governmentenforcing laws and regulations That said, it is important that the billing manager or chief financial as well as updates published by CMSinvolving all HHS divisions, including and your Medicare Carrier on theirthe Center for Medicare and Medicaid officer play a central role in developing the compliance program, since they respective Web sites. Commercial 2
  3. 3. payors will also frequently publish - Discount arrangement After initial training is completed,potential issues on their Web sites. - Credit balances mandatory refresher courses for bothAdvisory opinions published by the general and position-specific trainingHHS OIG can be found at www.oig. Training and Education should be offered at least once a Creating training and educational initiatives for individuals within the Monitoring and AuditingPolicies and procedures organization – including physicians, Tracking or monitoring the efficacy ofPolicies and procedures are the billing managers, coders and office a compliance program is accomplishedheart of any compliance program. managers – is next. Training should through regular assessments of workGenerally speaking, policies need to be be developed along two tracks: products and processes. For example,constructed around specific risk areas. Comprehensive training that includes a supervisor in the billing area couldClearly defining appropriate procedures general regulatory guidance for pull 10 bills each week to ensure thatand protocols for those aspects of the new and existing employees, and all data fields were properly completed,business subject to regulatory authority specialized training for unique the diagnoses were appropriatelyis critical to successful compliance. job positions and roles within the linked and the information enteredCompliance directors can utilize the organization. matched the charge documentOIG Work Plan, Model Compliance completed by the physician. From thisGuidelines and the appropriate CMS An example of a comprehensive process, areas of deficiency will beregulations to craft specific rules training topic would be educating readily apparent. These deficiencies,regarding employee or physician physicians and staff about the in turn, can become the focus of aperformance and expectations. appropriate use of the Advanced more formal and comprehensive audit Beneficiary Notice (ABN), a Medicare process.Some examples of policies that should document used to inform patients thatbe defined include: a particular service may not be paid Audits provide valuable snapshots of- Privacy and confidentiality for by Medicare and as a result may be overall compliance performance. It is the patient’s financial responsibility. An frequently worthwhile to conduct a- Record retention preliminary or baseline audit before example of a position-specific training- Practice standards topic would be educating coders the compliance program is initiated about the correct use of Modifer 25, a to gain additional insight into specific- Coding and billing processes coding designation used to ensure that risk areas and vulnerabilities. Like- Documentation compliance programs themselves, a particular office visit is considered- Standards of contact as “a significantly separate service” audits need to reflect the from other procedures performed on organization’s highest-risk activities.- Financial policies the same patient the same day and therefore can be billed separately. 3
  4. 4. Enforcement and Discipline Organizations that take complaints About the author:Compliance directors should also seriously, thoroughly investigate Bess Ann Bredemeyer, BSN, RN,formulate clear policies that outline questionable actions and promptly CHC, CPC joined McKesson inspecific consequences for employees act to mitigate violations once they 2005 and is Director of Compliancewho fail to meet or adhere to defined are identified will create a culture ofstandards or procedures. heightened compliance awareness Services, responsible for consulting throughout the organization. services related to physician codingDisciplinary programs should be and compliance practices. She hasprogressive in nature and be linked to An Ounce of Prevention more than 22 years of healthcareappropriate remedies, ranging from In today’s healthcare environment, experience and was previously theadditional training and education to regulatory mistakes can enormouslytransfer, suspension and termination. damage an organization’s finances Compliance and Privacy Officer for and reputation. It is therefore critical a large academic health scienceFor example, if the baseline audit that physicians establish, execute and center. Bredemeyer has also workedreveals that a specific provider is sustain compliance programs that with healthcare defense attorneysmaking significant and/or repetitive effectively address high-risk regulatorydocumentation errors, then that and physician state licensing boards areas. These programs will mitigateprovider should be informed of the providing coding, compliance, billing compliance risk and also help buildproblem and his or her performance good will with regulators. In addition, and privacy consulting services. Sheshould be included as part of a follow- they can help streamline revenue cycle has guest lectured at physician forumsup audit. If necessary, re-training operations and improve cash flow. and residency programs, and she hasshould be provided. If the problem taught graduate classes includingpersists, additional training should be This article is the first in a series ofmandated, along with a requirement three articles by Bredemeyer on health law and physician practicethat the provider reimburse the compliance and physician practices. management. Bredemeyer received hergroup for the cost of audits and Bachelor of Science degree in nursingin-service. A letter of reprimand and chemistry from Texas Christianmay also be appropriate. Continued University in Fort Worth, Texas. She is adifficulties could result in suspension or certified professional coder (CPC) andtermination. member of the American AcademyMitigation and Prevention of Professional Coders (AAPC) whereThe success of any compliance she has held several senior positionsprogram ultimately depends on the including local chapter president. Sheextent to which the organization is is an active member of the Health Carecommitted to actively identifying andresolving regulatory problems. One Compliance Association and is certifiedway to build this commitment is to in healthcare compliance (CHC).create channels of communication thatallow employees, business partnersand others to easily convey regulatoryconcerns to the appropriate individualor department without fear of penaltyor retaliation. Anonymous hotlines areuseful tools in this regard.McKesson Provider Technologies5995 Windward Pkwy., GA 30005 1.800.789.6409Copyright © 2007 McKesson Corporation and/or one of its subsidiaries. All rights reserved. ART601-11/07 4