Use these guidelines to monitor compliance
June 1, 1998 4 minutes read
Use these guidelines to monitor compliance
The toughest part of any compliance program is monitoring and investigating potential fraud and abuse. How do you make it consistent, and how frequently should you conduct internal audits?
Some answers can be found in the federal government's own model hospital compliance plan, which can be found on the World Wide Web site of the Washington, DC-based Office of Inspector General. (See source list at left.)
But to find out how these guidelines would work in an outpatient setting, Outpatient Reimbursement Management asked four experts for their opinions and advice. Here is what they suggest:
· Establish consistent audits to monitor compliance and reduce billing problems.
"The first step is to have an independent organization do a random sampling of chart reviews," says Marty Karpiel, MPA, CHFP, president of Karpiel Associates - Ambulatory Care Consultants of Long Beach, CA. The company is a health care, emergency, and ambulatory care operations and reimbursement-focused consulting firm.
Cindi Peterson, ART, business manager of Rockford (IL) Ambulatory Surgery Center, says the Rockford center has contacted several consulting firms about conducting a baseline audit. Then the center's chief compliance officer will conduct quarterly random sampling for all specialty services.
All new employees in the billing and coding area at the Rockford center will be monitored by Peterson or the chief compliance officer for 30 to 60 days, Peterson says.
"More than likely we'll have that person's records monitored for their coding capabilities and coding proficiency, and we'll have to make some sort of evaluation system for new coders and billers," Peterson adds.
The chart audits should compare physician documentation with the Medicare forms, and look for inconsistencies, Karpiel says. This first audit might go back three to five years, says Sanjay Sharma, JD, MS, an attorney with Buckingham, Doolittle, and Burroughs in Akron, OH.
The best practice would be to conduct regular internal audits of randomly checking samples of records coded and billed, and combine these with periodic audits by consultants, says Sue Prophet, RRA, CCS, director of classification and coding for the American Health Information Management Association (AHIMA) of Chicago.
Regular audits should look for these signs of trouble, Sharma says:
- Are you finding only routine errors or a systematic repetition of mistakes that could be called fraud?
- Are you finding random errors, or are these systematic problems that occur every three months or six months and have been going on for three years?
If a facility finds only a few cases in three years, or if every year the number of mistakes diminishes until they have disappeared, then maybe the mistakes have been corrected, Sharma says.
"But if you sample every month and a certain percentage of mistakes are made, then that's a light bulb that there's a problem," Sharma adds.
· Investigate and fix any problems you find.
"Once you've identified a problem through auditing or monitoring, then you need to conduct an internal investigation of it, including reviewing all pertinent documents and coding guidelines," Prophet says.
Interview employees and physicians to find out how the problem started, Prophet advises. "And all of this internal investigation should be documented," she adds.
Facilities need to list who was interviewed, whether discipline was taken, and what was done to correct the problem and prevent it from recurring.
The Rockford center will rigorously address all infractions. Administrators will solve the problem by educating staff to correct mistakes or, if someone shows intent to defraud or repeatedly makes the same mistakes, the center will fire the employee, Peterson says.
"We will not tolerate an individual who either doesn't have skills for coding or who has skills but continually makes mistakes," she explains.
Prophet says, "If the problem resulted in an overpayment from any payer, then that money should be refunded to the appropriate payer, and there should be a follow-up at a later date to make sure the problem is rectified and isn't still a problem."
Karpiel and Sharma suggest facilities let their attorneys hire all outside consultants and auditors. This could provide attorney-client privilege to some of the information that is found.
Peterson says the Rockford center's compliance plan has been written under the direction of the center's attorney, and the attorney will be involved in all investigations and the hiring of auditing firms.
Finally, if the facility is confronted with a government audit or investigation, it's time to hire an attorney, Sharma says.
"There could be cases where the provider is 100% wrong and the problem is fraudulent, maybe even criminal, but in other cases it's only human error," Sharma says. "Then in other cases, the government is wrong, and with good resources you can fight it."
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