Federal probes gaining momentum; can you pass a compliance test?
Good intentions alone can still get you in hot water
News item: More than 100 federal agents descend on Columbia/HCA Healthcare Corp. facilities in El Paso, TX, investigating a series of anti-fraud issues, including possible violations related to upcoding and the three-day payment window.
News item: A Holyoke, MA, counseling center agrees to pay the government $608,000, plus a share of its profits for the next 10 years, to settle charges that it violated fraud and abuse laws, including upcoding.
News item: Hospitals in almost half of the states receive settlement letters from the Department of Justice as part of its three-day window billing investigation.
News item: President Clinton, noting health care fraud convictions have increased by 241% since 1992, proposes legislation to boost Medicare fraud enforcement tools, including adding stiffer penalties.
You don’t need a compass to see where health care regulation is headed. And it doesn’t stop there. About a thousand hospitals have been questioned about conflicts of interest in their ownership of home health agencies. In April, New York University Medical Center in New York City paid $15.5 million to settle charges that it submitted false research information that led to overreimbursement. A Texas hospice collected $12 million in payments because its medical records did not sufficiently document the need for the services.
If you feel a breath on the back of your neck, it could be coming from a federal agent. But don’t panic, say the experts.
Many of the mistakes the Washington, DC-based Office of the Inspector General (OIG) sees are honest, says Eileen T. Boyd, JD, deputy inspector general of enforcement and compliance at the U. S. Department of Health and Human Services. "Where mistakes occur once or twice, it may be a legitimate error," she says. "But when mistakes occur continually, the inspector general becomes suspicious."
What has caused hospitals the greatest number of problems is a pattern of mistakes even honest mistakes that comprise what the feds consider willful neglect of Medicare regulations.
How do you avoid that situation? "The biggest recommendation I have for HIM departments is to develop a compliance plan and really start evaluating their own coding practices," says Sue Prophet, RRA, CCS, director of classification and coding for the American Health Information Management Association in Chicago.
"It is critical that one has in place the procedures and systems to protect your organization. A compliance plan is best practice," adds Byrd.
The OIG recently released a model compliance plan for clinical laboratories. No such plan exists yet for coding, but the laboratory plan offers some insights into elements you might want to include. (For details of the laboratory plan, see related story, p. 83.)
But you also can devise your own compliance plan, says Charlotte Kohler, RN, CPA, vice president of diversified services at Helix Health in Baltimore.
Boyd, Kohler, and Prophet have these tips for developing compliance programs for coding or any of the other areas of fraud and abuse the government is investigating. The key elements include:
1. Develop a plan you can live by.
"It has to be a realistic plan," Kohler says. "If you put some ridiculous expectations in there, it isn’t going to be followed or useful." For example, if you say in your plan that you will conduct a quarterly compliance audit, make sure that every quarter you pull records, document problems, and address them.
2. Include a code of conduct.
That code should outline staff standards of behavior, says Boyd. Once developed, it should be disseminated and discussed. "Don’t just put it on a desk or a shelf somewhere."
The conduct code also should include what to do in difficult situations, says Kohler. For example, if there is disagreement on how to code something, what do you do? Who handles the problem?
3. Designate a compliance officer.
Boyd says one person should be in charge of training, education, and dealing with problems related to the compliance program. Having a plan in place is useless if there is no one to note complaints when it is violated.
4. Implement a training program.
Once you have someone in charge to handle education on the compliance plan, make sure staff are trained and that training is documented, Boyd adds. "If we go in and ask you if you have trained your staff on billing compliance, it isn’t enough for you to say yes," she says. "You have to prove it. Write down who you train, what you train them in, and when you train them."
Kohler agrees. "If you have a training program, make sure that all new hires have it before they start," she says. "If you don’t, you can have new hires making errors that will cost you later."
5. Develop an audit program.
Conduct internal audits or reviews of assigned codes. Outside consultants can be helpful, but Boyd notes it’s important for each department to know its own operation well enough to find errors. "You can’t say, Oh, the auditor didn’t tell us.’ That’s not an excuse. You have to know what’s going on a day-to-day basis," Boyd says.
"You can do a trend analysis. If you know there is a certain procedure that the doctor is doing and its frequency has jumped 150%, take a look at why. Is it because people need it or because it is a money maker? If you are doing it for the latter, then someone will catch it."
6. Publicize consequences of violations.
If you have a method for staff to report concerns or violations internally, make sure it is known, Boyd says. "People have to know where they can go with a concern, and they have to be sure that the concern will be dealt with seriously." Indeed, if you have a method of reporting, but nothing is done with a complaint, federal investigators may deal with you far more harshly, says Boyd.
"If you never say anything about a complaint, that puts you in a worse place if we come in and detect it. You have to ensure that the use of discipline against those employees is made public. Make sure that consequences for illegal or unethical behavior or for violations of a standard of conduct are seen."
7. Make the plan understandable.
Boyd says many organizations write a compliance plan but put it in unintelligible terms. "If you have employees with the reading [level] of eighth graders, put the plan in appropriate language. Having a mission or vision statement on the wall isn’t any good if no one understands it."
8. Follow your plan.
"One scary thing is that people will develop a plan and stick it in a three-ring binder so they’ll have something to show the OIG if it comes around," says Prophet. "But the next step is to periodically audit your business and coding practices to make sure you’re following your own plan. You can really hang yourself, probably even worse than if you didn’t have a compliance plan, if you have one and aren’t following it." These audits should follow your practices from admission through bill generation, she says.
All this involves major headaches, but Prophet says there’s a bright side.
"In a way I don’t see this whole thing as being entirely bad. For years the HIM profession has been screaming about poor documentation, incomplete documentation, and conflicting documentation, and everyone says, Well, there goes those medical record people running around trying to get physicians to do their charts.’ But now I think we have more empowerment, and people are starting to stand up and take notice that documentation really is important, and it does need to be complete.
"A number of HIM directors have told me that in a way it’s wonderful because now when they try to get somebody to do something they just casually mention the word fraud’ and the physician or business office suddenly perks up and listens."
Sue Prophet, Director of Classification and Coding, American Health Information Management Association, 919 North Michigan Ave., Suite 1400, Chicago, IL 60611-1683. Telephone: (312) 787-2672, Ext. 340.
Charlotte Kohler, Vice President of Diversified Services, Helix Health, 2330 W. Joppa Road, Suite 301, Lutherville, MD 21093. Telephone: (410) 847-6730.
Eileen T. Boyd, Deputy Inspector General, Department of Health and Human Services, 330 Independence Ave., Room 5600, Washington, DC 20201. Telephone: (202) 619-0070.
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