Address compliance to reduce risk of prosecution
Structured training, staff hotlines part of answer
With every health care provider in the country subject to government scrutiny of its billing practices, access managers are well advised to take a proactive approach to the issue of compliance.
That's the advice of Paul Chrencik, CPA, senior manager in the health care regulatory group at PricewaterhouseCoopers (PwC) in Harrisburg, PA. In fact, Chrencik suggests that providers deal with instances of noncompliance in their organization before somebody else does.
Through legislation such as the Health Insurance Portability and Accounting Act of 1996 (HIPAA), Congress has given the Office of the Inspector General (OIG) and the Department of Justice the power and the funding they need to take their investigation of fraud and abuse to a new level, Chrencik points out.
"That has set the tone in the [health care] environment. There needs to be quite a bit of due care in rendering patient care," he says.
One provision of HIPAA that may be extremely expensive to providers, he notes, is the Beneficiary Incentive Program, which allows individuals who suspect instances of fraud and abuse in their companies to call toll-free and report it. The incentive is that the individuals can get rewards, which typically have ranged from 15% to 25% of the revenue from fines levied against the offending organization, Chrencik says. In a recent case involving pharmaceutical giant SmithKline Beecham's network of clinical laboratories, the company settled for $360 million, he adds.
Law firms, meanwhile, are receiving so many inquiries regarding whistle-blowing from employees concerned about their companies' practices that some attorneys now specialize in this field, Chrencik says. He recalls one "whistle-blower Web site" through which a law firm refers individuals to legal counsel in their area.
The False Claims Act allows the government to "drop the hammer" in two ways, Chrencik says. One is through exclusion from the Medicare program. The other is through fines. Thanks to provisions in the Balanced Budget Act of 1997, fines of $5,000 to $10,000 can be imposed for each false claim and then tripled.
Several preventive actions
In an environment fraught with such danger, there are several preventive actions access managers should consider, he suggests:
o Improve education and training.
"What we have seen is that individuals [in health care] at the department level are not receiving the training they should with regard to job responsibilities and how processes and procedures work within their activities," Chrencik explains.
"In registration, this includes [for example] the Medicare secondary payer screen and understanding physicians' written and verbal orders." Unlike with other industries, such as banking or manufacturing, health care organizations usually have not taken the time to provide structured training, he notes. In most cases, Chrencik adds, there is either no training or minimal on-the-job training.
"A significant piece of compliance is having [employees] understand that compliance activities are part of their day-to-day responsibilities," he says. "These are things you should be doing regardless of [the threat of government scrutiny], but that's what makes you do it."
o Establish a hotline of your own.
Deal with your compliance problems in a timely fashion, before the government does it for you, he advises. Establishing a hotline in one of two ways can help, Chrencik says.
One option is an in-house toll-free number that goes into a phone line monitored by the hospital's compliance officer. Callers must be allowed to maintain anonymity, he stresses, and there should be policies and procedures in place to follow up on complaints.
Or you can engage an outside vendor to provide hotline services for your organization, Chrencik says. "They will set up a toll-free number, screen the calls and provide the information back to you to deal with."
Under OIG's Compliance Program Guidance for Hospitals, he notes, it is suggested that acts of noncompliance be reported no more than 60 days from the date they are discovered. Chrencik emphasizes, however, that these are guidelines, not legislation.
o Look ahead when examining practices.
"Look at what you're doing today and if you're doing something incorrectly. If so, stop and fix it before you go back and look at the past," he says. "I'm not saying you don't look at the past, but before you do, make sure you know what you're stepping into."
Once a violation is reported, Chrencik adds, the government has the ability to come in and do a full investigation. "You need to be prepared to deal with the issues you've uncovered and understand how significant they are."
o Improve communication with the business office.
There should be regular meetings between access services and the business office, suggests Dolores Liddick, associate with PwC's health care regulatory group. "Very few places do that except in a crisis mode," adds Liddick, who has 18 years of experience in hospital registration, admissions, and patient accounting.
"Patient accounting usually gets all the regulatory changes, and they need to get them to [access services], so the people on the front end can see how they need to change," she says.
o Consider putting a coder in the access department.
A certified coder is more aware of the information that's needed and whether an account is coded accurately, Liddick points out. She says some hospitals have instituted pilot programs putting coders in access.
o Make sure your compliance software programs work.
With software products that input data from your carriers' medical review policies, make sure you have the ability to make changes as the regulations change, Liddick says. "Some [vendors] might say, 'We can change it, but it will cost you a lot.'"
Don't use software that automatically assigns diagnosis codes, just putting them in because they match, she advises. Most medical necessity products simply load in codes, based on medical review policies and flag anything that doesn't match, she points out.
o Don't use "cheat sheets."
"You can go into facilities where, for example, [staff] registering patients for radiology have a list of codes they can use," she says. "If they haven't been given [a code] by the physician, they just use what they have. Or maybe they've been given a list by radiology, which says, 'Here are the codes we use.' You don't know why they've given you the list. Maybe those are the reimbursable ones."
Don't use these kinds of shortcuts, Liddick advises. Don't assume that a certain code always goes with a certain test. "The issue," adds Chrencik, "is that the employee is more coerced to use the cheat sheet than to follow the correct protocol to get the code." What the employee should do, he says, is either call the physician's office to get the information or, if there is a written diagnosis on the order, find the right code using an ICD-9-CM reference book.
o Educate the physicians.
"It's to your benefit to get doctors educated," Liddick says. "What I have found is that it is important to find people who can talk to the doctors on their level. And it's not always the doctor who's giving the code. Talk to the practice manager and provide medical review policies from the [Medicare] intermediary so they know what's needed to get the bill submitted."
Some providers she has worked with schedule meetings with practice managers every month or designate a liaison between the facility and the practice. If cooperation is not forthcoming, the provider may want to take stronger action, she points out. "Some [physicians] are a great risk to the organization. You may not want to work with those who won't comply."
Perhaps the most important piece of advice, Chrencik suggests, is to implement the basic practice of making sure [employees] understand the compliance risks associated with their activities and how significant those risks are to the organization.
"It's easy to say, 'Just fix it,' but in the average health care organization, things don't happen overnight," he adds. "One of the biggest challenges is having the culture adapt to the environment that needs to be present for effective compliance control."
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