If the words “fraud” and “abuse” have not become part of your everyday language, they need to be. With the federal government’s continued focus on health care fraud and abuse, independent physicians and small group practices are at risk, as are larger integrated delivery systems. Over the past several years, the Office of the Inspector General (OIG) has recovered hundreds of millions of dollars as a result of their investigations, and it looks as if there is no end in sight.
Monitor Your Practice
Practices should meticulously monitor the following activities in an effort to avoid liability: medical necessity; coding at a level higher than your documentation supports (upcoding); double billing; and billing for services not rendered.
- Medical Necessity: Document, Document, Document! If a service is not documented appropriately in a patient’s chart, it didn’t happen. Always include complete documentation of diagnosis and symptoms, warranting the performed services.
- Coding: Ensure that staff is appropriately trained on the intricacies of your specialty’s coding requirements and the rules and regulations associated with improper coding. Provide as much training and education as possible and create a culture that supports ongoing training for annual updates. Furthermore, perform periodic chart audits to ensure that documentation coincides with billed charges. Document the results and any improvements that you have implemented as a result of the chart audits to demonstrate your commitment to regulatory compliance.
- Double Billing & Services Not Rendered: Develop and implement a system that allows you to monitor when a bill was sent and when the corresponding services were provided. If your practice is automated, your computer system should be able to track this information. Discuss options with your vendor and assign responsibility to a staff member.
Prevention is Key: OIG’s Seven Basic Elements
The best way to deal with the threat of an audit is to prevent one from happening in the first place. Take the initiative and address your practice’s activities before someone else does it for you. Initially, you should create a culture that does not tolerate non-compliant behavior. Discuss the issues with your staff and educate them on the importance of developing and adhering to a compliance program.
Although a compliance program needs to be specific to your practice’s needs, there are seven basic elements that are recommended by the OIG to avoid fraud and abuse sanctions. They include:
- Record, in writing, all compliance policies and procedures. Be sure to address areas and elements that are specific to your practice and specialty.
- Establish a compliance training and education program for the physicians and employees in your practice.
- Appoint a physician or staff member responsible for implementing and monitoring the program.
- Develop and implement a system to receive, respond and monitor allegations and complaints from your internal and external customers.
- Establish evaluation tools and techniques to monitor compliance and address existing and potential problems..
- Investigate and address all problems. Make it practice policy to discipline, even dismiss, staff members who are non-compliant or foster non-compliance.
- Provide protection for staff members who identify existing and potential compliance problems and issues. Create a culture that not only supports, but also rewards employees who identify potential liabilities.
Although implementing a compliance program may seem like an unachievable task due to staff and resource constraints, begin with small steps and always remember to document.
How the AANS Can Help
To assist its members, the AANS Education and Practice Management Department is in the process of developing programs to help AANS members become compliant.
- 2000 course schedule: The AANS’ current course schedule is concentrated in coding and socioeconomic issues. Courses are: “Mastering Expert Techniques in Neurosurgical Coding,” “Managing New Reimbursement Challenges in Neurosurgery,” “Designing Better Business Systems” and “Anatomy and Terminology for Office Staff.” (See page 9 for course descriptions.)
- Coding hotline: The hotline provides AANS members with convenient access to expert coding advice at discounted rates. (For more information, see page 9.) ยท Compliance program development: The Department of Education and Practice Management is in the initial stages of investigating resources for the possible development of a template compliance program.
- Annual meeting programs: At the 2000 Annual Meeting, the AANS provided members with an added benefit – a Consulting Corner and Strategic Management Symposium. Each focused on practice management issues.
- Record, in writing, all compliance policies and procedures. Be sure to address areas and elements that are specific to your practice and specialty.