OIG likely to adopt recommended billing guidelines for physicians
Internal committee has October deadline
Taking the bull by the horns has paid off for a national physician billing association that proposed billing standards to a government entity charged with policing compliance.
Sources tell Physician's Payment Update that the Washington, DC-based Office of Inspector General (OIG) has set an Oct. 5 deadline for members of its internal review committee to file their comments on a new set of compliance guidelines intended to cover reimbursement policies and procedures for both physicians and outside billing and claim processing firms. The proposed guidelines are largely based on recommendations filed with the OIG by the Bethesda, MD-based International Billing Association (IBA).
"Since billing is a basic activity involved in almost any kind of fraud-and-abuse question, we decided it would be better if the industry took the initiative and gave the OIG a compliance proposal, rather than waiting for them to just come out with something," says L. Stephan Vincze. A consultant to the IBA who was active in drafting the proposed standard, Vincze is president and CEO of Vincze & Frazer in Atlanta.
"From what I've seen, I do not expect any significant changes between the initial and final draft," says one source close to the OIG process. The new guidelines are expected to be published "very soon" after the final review comments are logged, say compliance experts. "It's possible they could be released and become effective during October, certainly before the end of the year," says one source.
The original compliance proposal drafted by IBA focuses on eight specific issues of critical importance to an effective billing compliance program:
1. Balance billing. This is the illegal practice of billing beneficiaries the difference between the total provider charge and the covered Medicare payment. Medicare beneficiaries, however, are liable for 20% of coinsurance plus the deductible.
"It may seem overly fundamental, but one of our basic premises is that a proper compliance program will not permit balance billing to occur," says Vincze.
2. Coding. Because not all billing organizations or physician practices do all their own coding, the plan addresses the responsibilities of organizations using either internal or outside coders.
"Whether the practice does it own coding or relies on outside vendors, it has an obligation to ensure that its claims are processed with the proper coding," says Vincze. "Ignorance is not a defense for improper coding. As such, we recommend that practices and billing companies include provisions in their billing/coding contracts that ensure quality coding and clearly outline each side's expectations and responsibilities in this area."
For instance, if either the billing company or practice finds examples of improper coding, it should be required to notify the other of the problem.
In either case, the practice's compliance plan should contain policies and procedures for continuously training coders in accordance with the latest coding and reimbursement information from HCFA and other sources, IBA recommends.
Vincze says HCFA auditors are paying particular attention to such inappropriate coding practices as unbundling, upcoding, and assumption coding, and the practice compliance program should emphasize these areas. "Look for auditors to become much more particular when it comes to so-called assumption coding - where a coder 'assumes' a certain higher-paying diagnosis like pneumonia rather than the flu from a chest X-ray without the proper medical documentation to back it up," notes Vincze.
Practices also should be careful about the incentives they offer coders to be productive. For instance, if coders receive a percentage of revenues, this can create an incentive to upcode.
"The good news is, if you do these kinds of things up front, should investigators find potential problems later on it's very likely they'll assume it was simply an innocent mistake or error and not part of a larger problem," says Vincze.
3. Collections. Whether it is the billing company or the practice, if you engage in any kind of payment collection activities, make sure you are in compliance with the Fair Credit Billing Act, the Fair Debt Collection Act, and any other relevant federal and state laws.
4. Confidentiality. Ensuring confidentiality of patient medical information could be the next major area of scrutiny from compliance investigators, the IBA says. As such, employees need to understand the importance of not discussing patient information. "There must be adequate safeguards of the information about patient claims and medical information contained in increasingly popular electronic data transfer technology," notes Vincze.
5. Credit balances. When an insurer makes an overpayment, a credit balance exists. A periodic credit balance review will uncover overpayments. However, "some physicians do not conduct periodic credit balance reviews, feeling it is the responsibility of the insurer to identify overpayments," Vincze says. "This is a risky assumption in today's climate." HCFA will look more kindly upon providers who voluntarily return overpayments than upon providers who wait for HCFA to discover the error, he says.
6. Discounts as a professional courtesy. Given the focus on illegal referral and kickback schemes, the IBA recommends physicians make it a practice not to waive deductibles for patients charging only the insurer for clinical treatment. "In all likelihood, this would constitute a false claim under the Federal False Claims Act," says Vincze. "Therefore, professional courtesy and promotional discounts are only appropriate if the total fee is waived or discounted."
7. Documentation. Physician organizations must ensure that accurate and complete documentation exists for all claims, and that the documentation is signed by the physician and includes the proper provider ID number. "Sounds simple, but physicians must remember that because poor documentation, unreadable signatures, and stolen provider ID numbers are basic tools of the Medicare con artist, these are also the kind of things investigators look for," notes Vincze.
8. Medical necessity. First, only a physician should be allowed to determine medical necessity. Then, the diagnosis needs to be thoroughly - and accurately - coded and documented.
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