Providers lobbying OIG for changes in small practice compliance guidelines
Providers lobbying OIG for changes in small practice compliance guidelines
Final document expected to be formulated by the end of the year
Anticipating the Office of the Inspector General’s (OIG) finalized compliance guidelines for small and solo physician practices by the end of the year, provider organizations have started a lobbying effort to make a number of changes in the original proposal.
Most physician-related societies have applauded the OIG for attempting to make its proposed guidelines more flexible, especially when compared to its previous guidances for other provider categories. For instance, most appreciate the fact the OIG did not insist small practices install a special hotline or 800 number for employees to report questionable activities. Instead, the guidelines state that an open-door policy would be sufficient.
However, while advocates like the Medical Group Management Association (MGMA) in Englewood, CO, believe the OIG is on the right path, "we still have several concerns regarding the draft guidance," says MGMA president William F. Jessee, MD.
Overall, the MGMA says the guidance is too complicated and should be scaled back. Specific changes MGMA and other organizations want the OIG to make include:
• Voluntary nature. There’s a Catch-22 in the guidance. Specifically,
the OIG says the guidelines are a voluntary document practitioners
can choose to use or not when designing their compliance programs. However, in several places through the draft guidance, the OIG uses terms such as "mandatory" and "essential" when describing program elements.
For example, "written policies and procedures are essential to all physician practices, regardless of size and capability," says the OIG. Providers want the OIG to remove such references to underscore that the guidance is, in fact, voluntary.
• Reference binder. The OIG suggests that a practice create a "binder" containing relevant Health Care Financing Administration (HCFA) directives and carrier bulletins, and summaries of key OIG documents, such as special fraud alerts, advisory opinions, and inspection and audit reports, to help stay current with regulatory requirements.
Provider groups say this may be too daunting a task for most small practices, and they are asking OIG and HCFA to create such a reference binder and distribute it for free to practices. Or, if that is too complicated, they suggest placing the material on a specified Internet site that could also be easily updated.
Standards for carriers
• Reasonableness. The MGMA wants the OIG to remove the "reasonableness standard" from its discussion regarding a practice’s reliance on carriers. Under that standard, the OIG notes that when a physician practice requests advice from a Medicare fiscal intermediary or carrier,
the practice should document the request and any response. This documentation may later become important when deciding if the practice’s reliance on the carrier’s advice was "reasonable," should compliance questions arise.
Rather than trying to determine if the practice’s interpretation of a carrier’s advice was reasonable, "carriers should be held to a certain standard to provide practices with reliable information so practices do not have to question whether they can reasonably rely on the information," argues Jessee.
Providers are also lobbying for a mechanism that will generate more uniform interpretation of Medicare regulations by different carriers. In turn, this could reduce the sometimes conflicting information physicians receive from those intermediaries. One suggestion is that carriers be forced to place any advice or interpretation they give a provider in writing.
• Physician as compliance officer. Besides the office manager or primary biller, the OIG should specify that a physician can also serve as a small group’s compliance officer.
• Training and education. The draft guidance says simply providing individuals with compliance-related documents to read and learn on their own does not constitute a suitable training program. It also endorses the idea of using newsletters and bulletin boards as part of the compliance training and education process. To make training less complicated for smaller practices, providers want the OIG to declare that just utilizing a newsletter
or bulletin board will satisfy the training and education provisions of the guidance.
• Auditing and monitoring. The MGMA does not like the OIG’s recommendation that practices conduct a "baseline" compliance audit as part of the auditing and monitoring process. This decision should be left to each practice, it says. "It would be quite costly for many small practices to conduct a statistically valid baseline audit," says Jessee. "We believe practices can effectively monitor and review their bills and medical records without necessarily conducting a baseline audit."
• Disciplinary guidelines. The OIG stresses the importance of implementing enforcement and disciplinary guidelines in order to put teeth into a compliance program. MGMA believes, however, that the OIG goes too far when it states that a practice’s enforcement and disciplinary procedures should "stipulate that individuals who fail to detect or report violations of the compliance program may be subject to discipline."
While it is reasonable to punish individuals who fail to report violations, "it is counterintuitive to discipline individuals for something they know nothing about," argues the MGMA. It wants the OIG to remove the word "detect" from the guidelines or at least modify the statement so just individuals who "reasonably should have detected violations" are subject to discipline.
• Response to detected offenses. The draft guidance states that "if a violation occurred and was not immediately detected, [the physician practice’s] compliance program may require modification." The MGMA says the effectiveness of a practice’s compliance program should not necessarily be measured based on how fast it detects a violation. As such, it wants the term "immediately" removed.
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