OIG preparing to provide guidance with model compliance plan
Plan will help practices’ problems with investigators
High-priced representatives from physician and specialty societies continue to meet with lawyers from the Office of the Inspector General (OIG) to hammer out the details of a much-anticipated OIG model plan to help physician practices comply with federal health care regulations.
Word from inside the OIG is that the guidance officially announced last fall should be out "soon." Once floated, the model plan will be the latest in a series of six previous provider-type specific guidelines developed by the OIG. They serve as a template for establishing what government officials will accept as a creditable and good-faith effort by practices to comply with federal health care payment and contracting rules. Adhering to those guidelines will be important because the existence of a well-run compliance program promotes a presumption on the part of auditors and prosecutors that payment problems are innocent mistakes rather than knowing efforts to defraud the government. In other words, providers that have what auditors feel are questionable billing patterns but also have an OIG-sanctioned compliance program in place will not automatically be considered con artists. Those without an OIG-sanctioned plan may be presumed to be crooks or at least to be hiding something.
Thus far, the OIG has built all its model compliance plans around the seven concepts its feels form the foundation of a good compliance program. (See related story, p. 18.) A major issue has been whether the OIG will continue to follow that seven-point blueprint — which it is inclined to do — or take another approach.
During negotiations with the OIG, physicians’ representatives have argued for a set of simple straightforward guidelines that stress assistance and a presumption of innocence instead of a rigid set of rules providers must follow. At the same time, physicians have asked the OIG to provide extensive details about what each guideline means, which the OIG has declined to do in previous guidelines in order to promote flexibility.
Taking the position that size matters, organizations like the American Medical Association have lobbied for the guidelines to be sensitive to the size and specialty of practices and to make distinctions between individual and small/larger group practices.
Arguing for an "outside the box" approach to writing the compliance guidelines, the American Society of Internal Medicine-American College of Physicians (ASIM-ACP) has taken a "please don’t make this too complicated; we’re just a bunch of physicians" approach. For instance, in a letter to Inspector General June Gibbs Brown, ASIM-ACP noted that besides not having the staff or time to implement a complex compliance plan, "the OIG needs to be aware that . . . the vast majority of physicians do not know what a compliance plan is, and some may only have a vague idea of what OIG does."
Stripped-down plan sought
ASIM-ACP is pushing for a stripped-down approach to compliance for physicians that will accomplish these goals:
• help physicians identify internal weaknesses in claims submission accuracy and completeness;
• provide up-to-date information on any areas the OIG feels are most vulnerable to fraud and abuse and, therefore, intends to make an enforcement priority.
Here’s where the needs of the typical practice and the OIG’s fraud busters come into conflict. While it makes good sense for the OIG to identify potential problem areas, dishonest providers can use that information to bilk the government. OIG officials also say they already provide enough information in the agency’s annual work plan and its advisories to identify enforcement areas it will focus on during the coming fiscal year.
To promote a "presumption of innocence" attitude in the guidelines, some physician groups want the OIG to develop a checklist or other mechanism to help practices identify internal weaknesses in their claims submission process.
"One key component of a physician compliance guidance should be a mechanism for identifying patterns of problem billings, either an in-house tracking system for the nature and volume of rejected claims or a profile of claims payment history for each practice generated by the carrier, says ASIM-APC president Whitney W. Addington, MD.
The goal would be to identify and correct problem claims faster and earlier in the process to minimize errors, denials, and, in turn, the need for audits and investigations. Another option would be to help carriers standardize reporting to physicians on specific claims coding and documentation problems, and to identify possible remedies supplemented by face-to-face physician/carrier educational sessions, says the ASIM-ACP.
Because the seven basic compliance program elements are based on federal sentencing guidelines, insiders are saying the OIG will not eliminate them simply to accommodate physicians.
"Physicians are feeling inundated with regu latory requirements," says AMA spokesman E. Ratcliffe Anderson, Jr., MD, arguing that the AMA wants the OIG to keep its guidance as simple and flexible as possible.
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