ED compliance: Billing processes receive more attention

By Caral Edelberg

In late November, the Office of Inspector General (OIG) released it’s long awaited Compliance Program Guidance for Third-Party Medical Billing Companies. This critical document provides the compliance expectations of the Federal Government with a "boilerplate" for all billing processes, whether performed by an outside contractor, within the medical practice, or by the hospital as a service provided to physicians. This compliance program, available for download on the HCFA website (http://www.dhhs.gov/progrog/oig.), provides a step-by-step approach to assuring the accuracy and legality of claims billed to payers.

The government has long been interested in increasing the monitoring efforts of the claims management industry as another layer of protection from fraudulent claims. The rapidly increasing complexities of coding and billing have far surpassed the reimbursement expertise of many physicians who, in ever-increasing numbers, are turning to professional vendors for assurances that the service is appropriately provided.

Until recently, billing vendors have enjoyed somewhat of a protection from sanctions that may be imposed on physicians’ clients who break the law. Under carrier policy, the physician is ultimately responsible for all claims billed in his/her name. However, recent audit activities involving medical billing firms have proven that billing companies that knowingly process fraudulent claims can be held liable as well.

Benefits of a Compliance Program

A well-developed, well-managed compliance program provides safeguards for providers and billing managers by incorporating rules, regulations, and sound business practice into one comprehensive plan. The compliance effort formulates effective internal controls that can be used as the standard by which the billing staff and client physicians can be measured. Such controls are guaranteed to result in improved processes—from improved medical record documentation from physicians by or through more objective billing policies for clerical staff. By formulating sound, written policies, the collaboration, communication, and cooperation between providers and administrative staff is improved.

Employees, whether clerical or clinical, often voice concerns about confusing billing rules and poorly defined expectations. Generally, no employee wants to increase the risk of audit by making mistakes. Yet the ambiguity of today’s billing rules, particularly the transitional documentation guidelines, the regulations governing billing for diagnostic interpretations, physician assistants, nurse practitioners, and teaching physicians, makes it nearly impossible to get a good, solid feeling of security on any front. This often holds true even with the clear, concise interpretations formulated by a cooperative effort between the billing company and the insurers.

A well-formulated compliance program provides some relief for these areas by providing those resources necessary to efficiently solve the problem for the providers and billing staff by assuring fast and accurate reaction to employee compliance concerns. Early detection and reporting of problems can be efficiently accomplished by outlining an effective communication process for all compliance concerns. For example, when a coder questions how to bill accurately for services provided by a resident assisting the attending physician in a teaching center, that information should be disseminated to all coders and catalogued in the coder policy and procedure manual to assure consistent and accurate coding of future teaching physician services.

Demonstrating commitment to quality performance of the billing process is an often stated but less often a proven component of billing system management these days. The difficulties and challenges are significant. However, the commitment must come from top management and trickle down through the organization for the mission to be realized. That places increased responsibility and expectations on the management/administration staff to create an atmosphere of excellence—excellence that can often come at the expense of profit because of the extraordinary expense required to hire and retain competent staff and assure the "latest in technology" that the job requires. With their incomes declining, providers are looking for the "best price" with little knowledge of what is truly at stake when the job cannot be done correctly.

Billing agencies will also be expected to rely on their compliance efforts as a means of identifying and preventing the threat of criminal/unethical conduct by employees and clients. In essence, they will be expected to use their compliance efforts to monitor the activities of everyone associated with the billing effort. To many, this other, "watching" mentality is the most onerous responsibility advised by the OIG. Any methodology for encouraging official reporting of suspected problems, as well as managing investigational procedures, presents significant issues for most billing agencies who must now assure that the internal controls and management policies are in place to deal with this potential problem. Further, employment of sanctioned individuals should be avoided, and, if it is identified by the OIG, can be expected to have an adverse affect the outcome of investigations. As part of internal control measures, billing agencies should assure that there are no financial incentives for either clinical or clerical staff that would encourage upcoding or performance of unnecessary services.

Having established the importance of monitoring all individuals involved in the process, the OIG expects the outcome to be, in part, an improved relationship with the Medicare contractor as the billing company and the carrier work together to assure the reliability of the process. However, there is real concern that such an expectation will do much to erode the trust built between the billing agency and the client, which is a necessary component of building a strong, effective relationship.

Controlling the Risks for Billing of ED Claims

Emergency medicine’s unique coding and billing challenges are, in part, brought about in no small way by payers’ inability to view our issues apart from the "normal" office-based practice. This demands that we manage a higher level of risk. This is created by the types of patients the emergency physician and emergency nurse manage, and the lack of a simplified means of translating that service into documentation, codes, and charges. In identifying the major areas of risk in the medical billing process, the OIG has included numerous areas of specific concern to emergency medicine.

Billing for items and services not documented is the highest priority for most physicians and billers. Many physicians do not understand the significant constraints placed on coders who must follow the coding rules while attempting to convert poorly or illegibly documented services correctly into dollars. A justified national paranoia has infected most coders and severely affected his/her ability to "call it as they see it," regardless of his/her years of experience or what he/she can read "between the lines." "Assumption coding" has drawn the attention of the OIG. Coders and physicians alike are well advised to avoid the expectation that services not clearly documented can be coded. This demands a realistic approach to how documentation is ultimately interpreted for the coding process. The physician ultimately benefits when the coder minimizes the providers risk from the inevitable audit. However, providers and hospitals are recognizing the negative financial results when risks are over-minimizing by applying the most restrictive coding policies to those payers that have distinctly more liberal policies.

"Upcoding" is of considerable concern to the OIG and billing agencies alike. Upcoding should be a term that only applies to intentional "overcoding" of services. However, it has been liberally applied to those incidents where the subjective coding rules leave much open to interpretation—interpretation of the documentation requirements imposed on the physician; interpretation of the coding rules utilized by the coder; and interpretation of both of these by insurers with limited knowledge of coding applications for the emergency medicine environment where government regulations demand that everything must be considered an emergency until proven otherwise.

Coders should be required to obtain clarification from their providers when documentation is confusing or lacks adequate justification. Providers, in turn, should attempt to minimize the number of records requiring clarification, while welcoming the coders’ attempt to code appropriately on their behalf.

Billing agencies can expect increased scrutiny of many components of the billing and coding process. For example, improper use of modifiers to obtain higher reimbursement will be monitored. Initially identified in the 1998 OIG Workplan, Medicare carriers have now been required to monitor the use of modifiers that result in higher payment. In emergency medicine, appropriate use of the -25 modifier should be outlined in each billing agency’s internal coding practice policy to prevent audit and penalties for improper use.

The billing compliance plan should provide assurances that coding will not be performed without proper documentation of all physician and other professional services at the time coding is performed. Holding claims until all the information is obtained should be a mandate for the coding process. Shortcuts to the coding process that are achieved by coding incomplete records in order to speed-up the billing within a three- to five-day deadline is risky. It is not uncommon to find emergency department (ED) unit clerks assigning diagnosis codes from the chief complaint entered on the ED log in an attempt to "get the codes in before the bill drops," and it often results in improper and inaccurate diagnosis codes. With use of diagnosis codes now more critical for determining the need and payment for diagnostic tests and the general medical necessity for ED services, no ED coding should be performed on less than the final, legal medial record.

Other risky behaviors identified by the OIG involve more of the "business" of processing claims. These include the failure to resolve overpayments, a constant conflict between some providers and their billing agents—the providers want to hang on to refunds as long as possible to counteract diminishing income, and the billing agency must manage repeated requests for refund from irate patients. In addition, casual application of discounts and professional courtesy should be addressed as part of routine compliance and discontinued if the practice exists. Medicare prohibits writing-off balances for their beneficiaries and may frown on the practice altogether if discovered in an audit.

Computer systems will come under increased scrutiny, too, as governmental agencies evaluate the integrity of the billing process and the growing use of new software developed to streamline the coding process. But in doing so, the software encourages liberal interpretations of coding rules by coders.

Coding and Billing Training

Policy should be developed for each billing and coding process and should be consistently updated in a written policy and procedure manual. At the same time, training programs should be updated to reflect ongoing revisions to policy and regulations affecting the daily operations. At the same time, providers should be informed of any responsibilities that may effect the documentation of the services. Competency in any function is assured through practice during training and in "real-time" performance. Compliance demands that all providers and billing staff understand the rules and can successfully execute the process.

Selection and retention of knowledgeable staff is a key component of success and demands development and ongoing management of an effective training program relative to the tasks to be performed. For example, the staff responsible for posting payments do not need to be trained on documentation requirements at the level provided to the physicians! The OIG Compliance Plan includes the following components of a comprehensive training program that can be readily adapted to the emergency medicine environment. Each, in its own way, represents a body of knowledge and expertise necessary for successful application to the specialty of emergency medicine:

• Knowledge of specific government and private payor reimbursement principles. Coding and billing must take into account the variety of plans and rules applicable to each payer and provide assurance that employees follow each appropriately. Research of regulatory and policy issues should be the assigned task of knowledgeable individuals. Management should be expected to identify the necessary resources and assign responsibility for research of the issues relevant to emergency medicine.

• Proper selection and sequencing of diagnoses. In the practice of emergency medicine, the chief complaint and/or symptoms often take precedence over the final diagnosis in establishing medical necessity for ED care. Coders must first be proficient in general diagnosis coding principals and, to that knowledge, must apply the unique requirements necessary for successful coding in the emergency medicine environment.

• Improper alterations to documentation. Billing, coding, and professional staff should be aware of the legal restrictions on altering medical records. Physicians are permitted to provide addendums to medical records when necessary. However, physicians should exercise caution in routinely altering medical records to provide the necessary text to comply with documentation rules unless deemed medically necessary.

• Submitting claim for physician services performed by non-physicians. Specific rules have been formulated to determine when services performed by non-physicians may be billed to the Medicare program and other payers. Billing personnel should be proficient in interpreting documentation well enough to ascertain the differences. This would include nursing staff, physician assistants, nurse practitioners, and residents.

• Proper documentation of services rendered, including correct coding rules. Clinical and billing staff should be able to recognize when documentation is deficient and code accordingly.

• Duty to report misconduct. More than any other component of the OIG Compliance Plan, this recommendation promises to be the most controversial. In essence, billing companies are encouraged to identify provider misconduct, advise providers to discontinue such activities if identified, and monitor to assure corrective action. If not corrected, the billing agency would be expected to either terminate the relationship with the client and/or report the inappropriate actions to the proper authorities. This recommendation from the OIG would supercede any confidentiality agreement generic to most contractual arrangements between providers and billing agencies. Misconduct by billing staff must also be dealt with quickly and, in severe cases where monetary overpayment from the government has occurred as a result of the offense, should be reported to the government for action.

Audits as the Cornerstone of Compliance

In order to demonstrate the importance of compliance to staff and providers as a company standard, a routine schedule of audits and quality assessment should be conducted and formally documented. To be effective, this program must function on multiple levels and involve the breadth of claims management. Often, outside auditors are required to provide an objective assessment of the coding and billing process. In addition, the management or compliance team should expect to conduct personal, on-site visits to each department to assess the daily process. Skills assessment may take the form of testing of billing and coding staff, surprise mock surveys, audits and investigations, examination of complaint logs, and interviews with management, operations, and coding. Tools for assessing the competence of staff may include questionnaires, review of personnel files for history of problems and documentation of corrective actions, review of written employee policies, policies and procedure for performing daily tasks, employee understanding, and use of resources and materials. Analysis of trends, along with longitudinal studies, are also a recommended as a means to identify deviations from established policies and documented norms.

Conducting Reviews of Provider and Billing Performance

As compliance audits must be relative to the task and area to be reviewed, reviewers must be qualified and experienced in order to adequately identify issues related to the subject matter. Reviewers would be expected to be objective and independent of line management and have access to existing audit and health care resources, relevant personnel and all relevant areas of operation in order to perform meaningful evaluations of competency. Following each routine evaluation, reviewers should be expected to provide written evaluative reports that specifically identify areas where corrective actions are needed.

Following scheduled internal reviews, management would be expected to take steps to correct any problems identified and revise policies and procedures, as applicable, to prevent future problems.

When Should I Develop My Compliance Program?

If you don’t already have a compliance program you’re way behind!! That’s how important an organized compliance effort is. At the very least, it puts clients and staff on notice that following payer rules and performing each task with the maximum of care and competence is of paramount importance. It establishes an expectation and provides the reassurance of its importance through routine evaluation. And it clearly states the corrective and disciplinary actions that will be taken when rules are broken.

Take some time, review the OIG’s recommendations, and begin the process of safeguarding your business, whether it be billing or delivering emergency care. For a quick review, follow these steps:

• Designate a QA manager or compliance officer;
• Define policies and procedures through written manual;
• Educate and train staff and management;
• Communicate expectations;
• Audit and monitor outcome and process;
• Discipline when necessary; and
• Determine corrective actions.