Correct coding a top priority for feds as the 2001 snooping plan is unveiled
Final physician practice compliance guidelines issued
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Two reports from the federal Office of the Inspector General (OIG) of the Department of Health and Human Services could affect how you practice medicine in the coming years, and how well your practice survives a federal audit.
The OIG Work Plan for 2001 identifies some 150 areas government health care auditors will scrutinize next year.
Among the areas that will affect physician practices are physician relationships with home health patients, critical care codes, services provided by non-physician practitioners, reassignment of physician billing numbers to clinics, and payment for physician services provided in teaching hospitals.
The OIG has also issued the final Compliance Program Guidance for Individual and Small Group Physician Practices. The final guidelines are essentially the same as the draft guidance issued in June although the OIG does make it clear that the guidelines are voluntary and gives physician practices some leeway in how they set up a compliance program. (For details on the OIG guidance, see PMC, September 2000.)
"It’s always good to look at the OIG Work Plan because it gives you a window to what the government is thinking and idea of what they will concentrate on," says Connie Raffa, a health law attorney with Arent Fox Kitner Plotkin & Khan, in New York City.
The OIG’s final compliance program guidance lists seven compliance program components, in the order they should be undertaken. These are: auditing and monitoring; practice standards and procedures; appointment of a compliance officer; training and education; responding to detected offenses; open lines of communication; and enforcing disciplinary standards.
However, the final draft makes it clear that a formal program is not mandatory and acknowledges that some physician practices may never be able to implement all the components.
"Small medical groups nationwide are pleased to see that the final compliance guidance is now more realistic and more do-able, especially for groups that lack the extensive resources needed to set up formal compliance programs," says William Jessee, MD, president and chief executive officer of the Medical Group Management Association in Englewood, CO.
However, Raffa warns that even if your practice doesn’t set up a formal compliance program, you should be taking steps to make sure that your physicians are coding correctly to avoid civil and criminal penalties down the road.
"Generally, physicians have got to become more familiar with the different coding levels. The OIG is paying increasing attention to that, and doctors no longer can rely on others because the OIG will hold them responsible for the mistakes, no matter who made them," Raffa says.
And, you should make sure that everything you bill for is carefully documented in an easy-to-read and legible format.
"No matter what the legal issues is, whether it’s upcoding or eligibility, it is crucial that physicians take the time to write information into the patient record to support their codes," adds Darren Binder, a health law attorney in the Washington, DC, office of Arent Fox Kitner Plotkin & Khan, PLLC.
Physicians tend to attract the attention of the OIG when they use the same codes over and over regardless of the circumstances of the patient, Raffa adds. "Physicians shouldn’t get complacent and rely on habits. They should make sure the code is supported by the specific dynamics of each encounter," she says.
Make sure medical necessity warrants the level of service being coded. Payers always apply the filter of medical necessity, Binder adds.
Often, an audit is generated when the carrier that has the contract for Medicare in a particular area examines the statistics from all the providers in that area. If a provider is billing too many patients at one level, especially if it’s a higher level, the computer kicks out that doctor’s name and looks at his or her billing practices more closely, says Mary Ann Swann, MBA, FACMPE, CPC, director of compliance programs for Baylor College of Medicine in Houston.
Medicare carriers are required by the Health Care Financing Administration to conduct sampling and audits of physician practices. They typically conduct random and analytical sampling. For instance, they may examine evaluation and management codes in a region and conduct a more intensive audit of doctors who have a higher proportion of 4 and 5 codes than their peers in that specialty.
Variances from the norm are a key source of triggers for an investigation, says Swann. "At a national level, they compare state data and see what codes are being paid, then ask the state to look at outliers," she says.
If yours is a specialty practice that sees the sickest of the sick patients, you want to make sure your documentation can explain it. However, Swann advises, keep in mind that even with expert interventions, not every service needs to be billed out at the highest level.
"When a patient is admitted to a hospital, initially services may be high but the level of service is expected to decline as the patients get better," Swann says.
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