Put head and heart into your CP
How to shift old practices to new
By Paula S. Swain, MSN, CPHQ, FNAHQ
Swain & Associates
St. Petersburg, FL
Billing office staff often wonder if and how they’ll ever use the information dispensed at teaching sessions about corporate compliance. They’re sometimes overheard referring to the meetings as "just more programs" they have to attend.
Not long ago, following just such a program, a billing clerk was approached by her supervisor with a request from administration to waive a copayment. The clerk was asked to put a note in the record to accept whatever insurance would pay. The bill covered the hospitalization of a high-level officer in the company. As the clerk began to search for the account, she had a flash of recognition. Just that morning she had signed the following statement:
As an employee you are expected to:
1. Read the compliance program (CP) policy manual and sign a statement that it was read and understood.
(In the manual were details about billing accuracy. The manual said false billing is very serious, and penalties are severe. Knowingly and willingly submitting false claims is a criminal offense, it stated, and even innocent errors can prompt an investigation.)
2. Report to the compliance officer any apparent violation of the hospital’s policies as stated in the manual.
3. Ask a supervisor or the compliance officer when you have a question about the legality of a course of action you are about to take.
The education that morning had paid off. The employee had acquired an empowered way of thinking. Will she act on the new information? The supervisor who requested that she adjust the bill was wrong, the administrator who had requested the bill be adjusted was wrong, and an ethical dilemma was created.
Proactively support staff from the inside out. A good way to help people deal with unavoidable ethical dilemmas is to develop a scenario involving fraud. Role-play. Practice with tough ethical questions. Get staff to rehearse with some agreed-upon answers. Then use the knowledge gained to help your organization evolve into compliance thinking.
New external issues need to be addressed as well. The 1998 work plan of the Office of Inspector General (OIG) states that the agency will conduct audits, reviews, and studies. Among them:
• A review of DRG coding. This will determine to what extent hospitals incorrectly code hospital discharges for Medicare payment. Reviewers will develop an approach to identifying facilities possibly engaged in inappropriate coding for more thorough review and proper remedial action. Approaches may look at changes in case mix, or may use commercial software to detect billing irregularities.
• An audit of short-stay discharges at non-prospective payment system (PPS) providers. This will:
Identify the extent of short-stay discharges from a PPS hospital and compare them to those of a hospital unit that is not part of the PPS.
Assess whether such stays were warranted.
Determine whether Medicare reimbursement should be adjusted if the beneficiaries were subsequently readmitted to the same PPS hospital that made the original referral.
• A review of observations stays billed to Medicare. This will determine the financial impact of miscoded hospital outpatient observations stays on the Medicare program and its beneficiaries. The Prospective Payment Assessment Commission (ProPAC) identified this as a problem area in 1994 because many observation stays should have been coded as inpatient admissions to the hospital. (See special section on observation status in the April issue of Hospital Peer Review.)
• An analysis of revenue codes billed by hospitals. This will determine the extent to which hospitals are inappropriately billing Medicare for noncovered items through the use of general revenue codes.
• A review of overhead costs. This financial analysis will determine what portion of Medicare payments to home health agencies is actually benefiting the beneficiary.
OIG senses that there are few incentives for agencies to control their costs and operate in a fiscally prudent manner. An analysis of a major agency disclosed that only 46 cents of every Medicare dollar paid to the agency was used to provide direct medical and aide services to beneficiaries.
• An audit of financial conflicts of interest. The OIG will examine nursing homes that have been purchased, partially or wholly, by durable medical equipment supplier chains or physician groups. The agency will look at claims submitted for Medicare beneficiaries in these homes and identify any aberrant billing patterns for services and supplies provided by owners with substantial financial interests.
• A review of nursing home care after less than three days of hospitalization. This will determine if payments for skilled nursing facility stays meet Medicare’s coverage conditions. Survey work in Illinois indicated some nursing home stays were reimbursed by Medicare, even though they were not preceded by the required hospital stay.
Focus on physician issues
• A review of hospital ownership of physician practices. OIG will assess Medicare billing practices and utilization when hospitals own physician practices. Vulnerabilities may include inappropriate referrals between hospitals and physicians, excessive costs and billing, and overutilization of services when hospitals bill the Medicare program through physician practices they own.
• An analysis of the use of surgical modifier. OIG will determine whether physicians are improperly using modifier -25 on their Medicare Part B claims to increase reimbursements. Modifier -25 is for physicians to claim "Significant, separately identifiable evaluation and management services on the day of surgery."
Consider the OIG’s initiatives, but evaluate practices that exist within the facility as well. Senior management will have to make a cognitive effort to identify violations that can occur in day-to-day practice. When the entire organization has been trained to react to vulnerable situations, test it.
As a final note, remember you and your staff may be tested as worried administrators look for potential problems in advance of Medicare investigations. Perhaps that message to the billing department from the administrative wing was a test by senior management to see how effective the compliance training was.
(Editor’s note: For a copy of the OIG’s 65-page work plan or more information about compliance implementation, e-mail Paula Swain at Paula@ SnAConsulting.com and leave a message. You can jump directly from the Swain & Associates Web site at http://www.snaconsulting.com to the OIG’s work plan by clicking on the hyperlink http://www.hhs.gov/ progorg/oig/wrkpln/wrkpln.html.)
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