The feds are watching your doctors; compliance plan can ease their woes

Creating a Medicare compliance plan can keep investigators at bay

Many of your physicians have experienced it: elderly patients, confused and upset, calling repeatedly to complain about Medicare copayments. The physician’s staff consider these patients annoying and are short with them, not explaining the billing process. The patients, angry at their mistreatment, call federal officials and allege that they are being charged for services not rendered. The result: an investigation into your doctor’s billing practices.

Are your physicians prepared for such scrutiny of their records? Most people aren’t, says Eileen T. Boyd, JD, deputy inspector general of enforcement and compliance at the U. S. Department of Health and Human Services.

Boyd has seen such situations during her years directing investigations. She says there are four common types of errors uncovered by investigators:

• billing for services not rendered;

• duplicate billing;

• billing for medically unnecessary services — for example, if the doctor orders a battery of tests rather than the specific test that is appropriate or medically necessary;

• not having a signed doctor’s certificate of need. "Some people have a stamp with the doctor’s name, not a signature. We ask for a signature on items ordered to ensure that the physician ordered the procedure, and it is medically necessary."

Many of the mistakes the Office of the Inspector General sees are honest. "Where mistakes occur once or twice, it may be a legitimate error," she says. "But when mistakes occur continually, the inspector general becomes suspicious." And what do you do when you find an error, asks Boyd. "If you pay it back, fine. Then, when we find a mistake, we will be much more understanding."

To avoid some of the problems to begin with, Boyd says you should set up a billing compliance plan. "It is critical that one has in place the procedures and systems to protect your organization. A compliance plan is best practice."

There are some great places to get information on how to write a compliance plan, says Charlotte Kohler, RN, CPA, vice president of diversified services at Helix Health in Baltimore. One starting point she suggests is the American Association of Medical Colleges (AAMC) in Washington, DC. "They really try to make sure that their members are aware of the benefits of compliance plans," she says. For about $100, Kohler says the AAMC will provide model plans to members.

Kohler also has developed a sample plan that others may find helpful. (For her plan’s compliance standards and procedures, see story, at right.)

Boyd and Kohler offer these nine tips for those in the throes of developing compliance programs:

1. Write 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 two physicians disagree 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.

Your billing, says Boyd, should be subject to internal audits. It’s no use hiring an outside auditor to find lapses if you don’t understand your own business, she says. "You can’t say, ‘Oh, the auditor didn’t tell us.’ That’s not an excuse. You have to know what’s going on, on a day-to-day basis."

Audits don’t have to be complex, Boyd says. For example, if you are in a clinical lab and you want to make sure the billing done by the lab is correct, do an annual analysis of billing to ensure that certain things you bill for are billed correctly. "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 violations, 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. Cover changes regularly.

Kohler says one of the biggest mistakes she sees are practices that don’t go over changes in codes regularly. "Make sure that at least every year, you and your staff cover coding changes and why they occur. We can all screw up and make errors. But it can look like you knowingly did it if you leave a wrong code in the computer."

8. Keep good records.

"You would be surprised how many good doctors don’t do this," says Boyd. "If you are the best doc in the world but you don’t keep a record of visits, then it’s your word against a patient’s."

9. 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 retention 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."

Boyd says the office of the inspector general will continue to look for Medicare fraud and concentrate through its project "Operation Restore Trust" on the five highest Medicare states: California, Texas, Florida, New York, and Illinois.

"June Gibbs-Brown, the inspector general, is working with the Health Care Financing Administration, the Department of Justice, the Administration on Aging, and the Federal Bureau of Investigation to target the areas where the most money is spent in certain health care areas," she adds. "We are making efforts to try to ensure that we are putting agents out there where people are engaging in fraudulent activity."