Compliance Planning

[Noelle]

Compliance Planning
by Dreama Sloan-Kelly, MD, CCS

The Federal government has become more and more vigilant on the submission of false claims. It is important for physician groups submitting claims to be aware of the liability associated with those claims and ensure that they are within the scope of the billing rules. In order to ensure that your practice in compliance it is important that your practice:
· Create and Implement a Compliance Program.
· Perform regular internal audits
· Have periodic audits performed by an outside source.
· Educate clinical AND business staff.
What does the OIG say?
The Office of Inspector General has recommended that all medical practices, whether big or small, create a compliance program. According to the OIG an effective compliance program consists of:
· Conducting internal monitoring and auditing
· Implementing compliance and practice standards
· Designating a compliance officer or contact
· Conducting appropriate training and education
· Responding appropriately to detected offenses and developing corrective action
· Developing open lines of communication
· Enforcing disciplinary standards through well publicized guidelines
Along with this, the OIG points out 4 specific risk areas that are noted in the medical practice:
1. Coding and Billing
2. Reasonable and necessary services
3. Documentation
4. Improper inducements
In their directive, the OIG states that it is important to create and implement a compliance program because it:
· Speeds and optimizes proper payment of claims
· Minimizes billing mistakes
· Reduces the chance that an audit will be conducted by HCFA or the OIG
· Avoids conflicts with self-referral and anti-kickback statues.
Many doctors often feel that the government, and private payers are out to get them. On the government’s side the OIG attempted to address this issue in the Federal Register by stating:

First, the OIG does not disparage physicians, other medical professionals or medical enterprises. In our view, the great majority of physicians are working ethically to render high quality medical care and to submit proper claims.
Second, under the law, physicians are not subject to criminal, civil or administrative penalties for innocent errors, or even negligence. The Government’s primary enforcement tool, the civil False Claims Act, covers only offenses that are committed with actual knowledge of the falsity of the claim, reckless disregard, or deliberate ignorance of the falsity of the claim.5 The False Claims Act does not encompass mistakes, errors, or negligence. The Civil Monetary Penalties Law, an administrative remedy, similar in scope and effect to the False Claims Act, has exactly the same standard of proof.6 The OIG is very mindful of the difference between innocent errors (‘‘erroneous claims’’) on one hand, and reckless or intentional conduct (‘‘fraudulent claims’’) on the other. For criminal penalties, the standard is even higher—criminal intent to defraud must be proved beyond a reasonable doubt.
2008 OIG Work Plan
Every year the OIG puts out their work plan which gives a clue to physicians and hospitals the areas they will be focusing on. The complete document is over 111 pages long and can be accessed online at:
http://oig.hhs.gov/publications/docs/wo ... Y_2010.pdf

In Summary:
· Place of service errors
· Evaluation and management services during global surgery periods
· Medicare payments for psychiatric services
· Services performed by clinical social workers
· Medicare payments for selected physicians services
· Medicare “incident to” services
· Appropriateness of Medicare payments for polysomnography
· Long distance physician claims associated with home health agency and skilled nursing facility services
· Assignment rules by Medicare providers
· Business relationships and the use of magnetic resonance imaging under the Medicare physician fee schedule
· Medicare payments for interventional pain management procedures
· Geographic areas with high utilization of ultrasound services
· Geographic areas with a high density of independent diagnostic testing facilities
· Payments for high frequency chiropractic treatments
· Physician reassignment of benefits
What does KSA and Dr. Sloan-Kelly recommend?
In working with many groups I have seen groups that were trying their best to stay compliant get hit with an audit and it take the wind from beneath their sails. On the other hand I have seen some practices that are grossly negligent and get by without ever having an audit. From these different encounters I have learned a few things that I think would be useful for any, and all, medical practices:
· Have no FEAR – do not be afraid – fear can cost you money, make life miserable, and ultimately destroy your practice. If you feel as though what you are doing is the appropriate way to do things then go for it, just make sure you have documentation to support any changes or policies that the practice is thinking about instituting. I think fear is a bigger detriment to the practice than anything else.
· Get a compliance plan – in a dream world we would have all of the time in the world to create a comprehensive compliance plan – and if there is someone in the practice that can do such a thing that is great (the OIG guidelines in the 2000 Federal Register is a good guideline). However if you live in my world, there is never enough time in a day. Therefore consider getting help with it, sometimes help can be very expensive, but KSA has a software product, ComplianceSelf, that can make the creation of a compliance plan simple and fast. Less than 20 minutes – NO LIE!
· Audits – just that word freaks me out and I am sure it does the same thing to everyone in your practice. There is no reason to freak out from an audit if all of your ducks are in a row. Internal audits should be conducted on a regular basis – we recommend at least once a quarter – pick a set number of charts and go to town. 20 a quarter is often a good number. If you need help in conducting your audits there is an awesome software that walks you through the whole process, AuditSelf. We also recommend for your group to have an external audit done once a year or once every other year by an independent outside source. Be sure to watch the cost. For instance, I do reviews for $300 but others may charge anywhere from $1000 to $5000.
· Education – the key to a successful practice is knowing how to get there and knowledge is the only way to get that key. Encourage those within the practice to go to regular seminars. Have someone come in and do a customized in service for the practice. If you don’t get the knowledge you don’t get the cash.
Customer service -- although I listed this last, it is probably the most important part. Communicate with patients clearly and nicely. They can spawn a negative audit faster than anything else. Your patients are your customers, and health care has become a very expensive commodity.