Your Compliance Program – it can keep you out of trouble!

A compliance program is supposed to be a preventive activity, identifying problems before they become serious issues.  It doesn’t happen too often, but it is sad anyway when you hear about someone involved with billing and accounts receivables going to prison.  And you think “A reasonable compliance program would have uncovered the problem and helped this person avoid this fate”.

A Compliance Program can help – most of the time

An effective compliance program should help uncover patterns of billing and medical record documentation that indicate there may be a problem with the claims being generated for services.  In the case of this person, the fraudulent billing involved claims for anesthesia services during endoscopy procedures that were padded with extra time – so much extra time that it was not humanly possible to have performed the services.  And the fraud was ordered and directed by the physician owner of the practice, so a compliance program may not have helped when larceny was the order of the day right from the top.

But most of the time, medical practitioners and other healthcare organizations are not setting out to commit billing fraud, and an effective compliance program can actually help.

An Effective Compliance Program is no accident

An effective compliance program does not come into being on its own, and is not effective without ongoing efforts to make it so.  The components of compliance programs for most healthcare providers are well documented.  They start with appropriate compliance program policies and procedures, include routine monitoring and auditing, and continuous training of staff and providers on compliance, documentation and billing issues.

An effective compliance program should uncover unusual patterns of medical record documentation or billing that seems to exceed the capacity of the providers in the organization to perform.  In one recent billing/medical record documentation audit, we noted one out of three providers was billing for almost twice the amount of visits the other two providers reported.  This type of finding can be a red flag, requiring discussion or perhaps additional investigation.  In this case, the medical record documentation of a sample of medical records of each visit supported the use of the CPT-4 codes for each visit, and the provider’s work hours supported his capability to have rendered so many more services compared to his peers.

In another instance, we found one provider was coding all of his office visits for established patients at the highest CPT4 code  level, while his peers had more of a normal distribution of CPT4 codes.  After first pushing off the CPT4 coding to his medical assistant, the provider agreed his coding was an issue, and he needed to match his use of a particular CPT4 code with the patient’s condition and his medical record documentation.

These are examples of a compliance program working as it should, identifying issues early, and introducing corrective action when necessary.

Your Compliance Program in an environment where questionable practices are ignored, or even condoned

What should you do when, as described above, fraudulent practices are prescribed by the leader of the organization?

In another recent engagement, we found the physician leader had instructed the outside billing service to bill for interpretations of a specific diagnostic procedure that, with certain exceptions, could only be billed once per day for patients in the hospital.  This went on for several years, with the acquiescence of the billing service manger.  It eventually resulted in a huge repayment settlement by the medical group, which promptly ended the relationship with the physician manager.  And the billing manager?  She is sweating bullets that the OIG does not come after her for knowingly going ahead with a practice she knew was wrong.  In this instance, she had the option of informing other physicians in the group of the practice, and ultimately, of resigning.

Everyone who has an independent duty to avoid fraudulent billing is required to report potential violations of the False Claims Act.  Failure to do so may make you a defendant when the wheels of justice start grinding.  An effective compliance program, supported by senior leadership, is the best protection against untenable situations for everyone involved in billing federal programs these days.

When you need proven expertise and performance

Jim Hook, MPH

Mr. James D. Hook has over 30 years of healthcare executive management and consulting experience in medical groups, hospitals, IPA’s, MSO’s, and other healthcare organizations.

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