Model plan on the way for docs and billing companies
The billing industry has jump-started the model compliance plan for physicians by submitting recommendations to the HHS Office of the Inspector General.
While there's no guarantee that the OIG will adopt all or even part of these, industry sources say initial reaction has been very positive. The recommendations focus on eight specific issues of critical importance to an effective billing compliance program:
1. Balanced billing.
Balanced billing is the illegal practice of billing beneficiaries the difference between the total provider charge and the Medicare payment. "It may seem overly fundamental, but one of our basic premises is a proper compliance program will not permit balanced billing to occur," says L. Stephan Vincze, a consultant to the Maryland-based International Billing Association (IBA), which initiated and sponsored the recommendations.
2. Coding.
Because not all billing organizations or physician practices do all their own coding, the recommendations address the responsibilities of organizations using either internal or outside coders.
"Ignorance is not a defense for improper coding," says Vincze. "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 party of the problem.
Also, practices 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. (See related story on physician practice management contracts, p. 1.)
3. Collections.
If you engage in any kind of payment collection activities, ensure you are in compliance with the Fair Credit Billing Act, 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, Vincze says. As such, "there must be adequate safeguards of the information about patient claims and medical information contained in increasingly popular electronic data transfer technology," notes Vincze.
Rita A. Scichilone, MHSA, RRA, CCS, a coding advisor for Professional Management Midwest in Omaha, NE, says one thing to pay particular attention to is whether a billing service is photocopying records. If so, "what’s happening to those records after they do the coding? Are they appropriately being destroyed, or are they hanging around in some billing service file where they’re not secure?"
5. Overpayments.
Periodic credit balance reviews should uncover most overpayments. But some physicians don't conduct reviews, believing it's the responsibility of the insurer to identify overpayments, Scichilone says.
"A lot of physician’s offices just don’t pay much attention to overpayments, and that’s a real concern, because if they don’t have a mechanism in place to assess that, then they have no way of knowing if they were paid appropriately, whether it be an overpayment or an underpayment," Scichilone says.
6. Discounts as a Professional Courtesy.
Given the focus on illegal referral and kickback schemes, 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," 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. The documentation must be signed by the physician and must include the proper provider ID number.
8. Medical Necessity.
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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