This is the second of a two-part series on regulatory bodies.
Neurosurgeons must comply with more than 132,000 pages of Medicare and Medicaid regulations. What can you do to protect yourself so as to minimize the risk of federal prosecution? There are three things that are absolute requirements: education, documentation and compliance.
The Necessity of Education
Neurosurgeons need to know the innumerable regulations promulgated by the government and others. Fortunately, there are many educational resources to assist you. The AANS and CNS offer courses and seminars on reimbursement and practice management. The American Medical Association offers a wealth of programs and educational materials, as do state and local medical societies and most hospitals. In addition, the medical industrial complex has created a whole new opportunity for private consultants, who, for a fee, can assist you on nearly every aspect of your practice.
The bottom line is that you must continue to educate yourselves on these practice management issues. Indeed, it is virtually a requirement of the federal government that you do so, as ignorance of the law is no defense.
Documentation
As residents, you are probably all too familiar with the Payment at Teaching Hospitals or PATH audits. Four early investigations of teaching hospitals under this audit program resulted in settlements in excess of $65 million. The largest problem was the lack of documentation to demonstrate that the service actually did take place and that the reimbursement was therefore appropriate.
You must have documented proof of the services you provide. Vague notes or references in patient charts are not sufficient. Two areas require specific attention: Medical Record Documentation and the HCFA 1500 Form.
The federal government requires that a medical record documents (a) the site of the service, (b) the appropriateness of the services provided, (c) the accuracy of the billing and (d) the identity of the caregiver.
Medical records should be complete and legible. Documentation of each patient encounter should include the reason for the encounter, any relevant history, physical examination findings, prior diagnostic test results, assessment, clinical impression, or diagnosis, plan of care, and date and legible identity of the caregiver. CPT and ICD-9-CM codes used for claims submission should be supported by documentation and the medical record. Finally, appropriate health risk factors must be identified.
The HCFA 1500 is the billing form that must be used to be reimbursed by Medicare. In completing the form, make sure the reason for the visit or service is linked with the diagnosis code. Use modifiers appropriately. Provide Medicare with all information about a beneficiary’s other insurance coverage.
Compliance
The Office of Inspector General’s compliance program (Office of Inspector General’s Compliance Program Guidance for Individual and Small Group Physician Practices, September 2000) is complicated and burdensome. Why should you attempt to understand it? The six criminal statutes highlighted in Appendix B of the report and the four civil and administrative statutes highlighted in Appendix C of the report!
The components of voluntary compliance are: conducting internal monitoring through periodic audits, developing written procedures for compliance, designating a compliance officer in your practice, conducting training practice standards, responding appropriately to detected violations, developing open lines of communication among employees about compliance and enforcing disciplinary standards through well-publicized guidelines. The OIG acknowledges that full implementation of all the above components may not be feasible for all physician practices. Note, however, that there is a general feeling that the lesser of two evils is to not have any compliance program as opposed to having one, but noot following it. Make sure that you set up a realistic plan and adhere to it!
Conclusion
Gone are the days when the practice of medicine was a personal relationship between doctor and patient. The exam room is now overcrowded and in addition to the doctor, patient and nurse, you will find your Congressman, HCFA, government auditors, insurance company bean counters, accountants, billing clerks, compliance officers and the dreaded lawyers. To counteract this, organized neurosurgery is helping to develop a comprehensive reform proposal similar in nature to the IRS reform legislation of several years ago.
As complicated as all of these may seem, it isn’t brain surgery. If you continue to educate yourselves on these issues and participate in the regulatory and political processes, you will be able to effectively deal with the governmental regulatory bodies and stay out of jail and prosper as successful practicing neurosurgeons.
Katie O. Orrico, JD, is director of the AANS/CNS Washington, D.C. Office.