Want to raise eyebrows? Advise a physician or medical practice that they’ll be paying to update, or implement, their compliance program. As medical practice consultants, we frequently discover that our healthcare and medical consulting clients need to update their compliance program. Here’s an anecdote “from the trenches” that demonstrates how consternation can turn to understanding.

Recently, Barbara Derry presented a proposal to a specialty group. Afterwards, one physician chastised her, feeling that our fees were too high for a coding and documentation audit. She left thinking that DNA wouldn’t win the project. Imagine our surprise when the practice not only hired us for the project, but also added compliance program redesign to the engagement’s scope. To top it off, they paid us in full by year-end!

The Office of Inspector General (OIG) and CMS dictates the guidelines that medical practices and other healthcare organizations must follow related to governance, coding and billing practices, and auditing and monitoring reporting structures. Some providers object, but there is no denying that rampant fraudulent billing occurs nationwide – particularly in the four test states (Florida, California, Texas and New York) of the 2005-2008 Recovery Audit Contractors (RAC) demonstration program. An effective compliance program can help avoid fraudulent billing.

How can you tell if your healthcare organization’s compliance program is effective? Here are common areas that DNA examines:

• Organizational behavior: Is the business philosophy compliance-driven? How is employee awareness and support? Physician compliance? Overall compliance program credibility?
• Compliance Awareness: What is the overall employee awareness of your compliance program? Its policies and activities?
• Oversight and response: What’s the activity level of the compliance officer and management in the regulatory process? Disciplinary consistency? Discovery and investigation? Error documentation? Employee satisfaction?
• Education Program: How many employees are educated, how often, and what are standard attendance percentages?
• Coding and claims accuracy: How well does the practice audit and monitor findings, such as coding and documentation errors, claim errors and claim rejection/denial percentages?
• Coding and claims processes: How many services are un-billable due to poor coding practices? How many claims are processed and properly use charge master and coding/claim technology?
• Corrective action: How usable and accessible are reporting mechanisms? What’s the interaction with carriers and intermediaries? How efficiently are reported concerns resolved?
• Quality Improvement Program: How responsive and adaptive is it to industry and regulatory changes? Does it efficiently distribute information? How is the business and financial success of the practice?

The OIG is very busy, determined to curb fraudulent billing practices and recuperate monies paid incorrectly over the past several years. There are literally hundreds of healthcare providers now under corporate integrity agreements (CIAs) that last five years. If a healthcare organization is under a CIA with the OIG, it means they must closely follow specified methods and activities that ensure they meet statutory and regulatory standards, and report properly. Discover the targeted areas at http://oig.hhs.gov/fraud/cias.asp.

Our advice? Be ready; be in compliance.

DNA Snippet
The Obama Administration says that it is going to crack down on improper payments made by all government programs, which in 2009 totaled $98 billion according to federal agency estimates. (GovernmentExecutive.com)

For help assessing or updating your medical practice’s compliance program, contact Derry, Nolan & Associates.

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