How to integrate physicians into your compliance plan

Integrating physicians into a compliance program is one of the greatest challenges facing hospitals, says Paul Belton, vice president for corporate compliance at Sharp Healthcare in San Diego. The reason is simple: Physicians still drive 75% to 80% of health care costs and control the documentation process.

According to Belton, there is a lot of confusion among physicians who have never been properly educated about many of the rules and regulations they confront on a daily basis. "There is a crying need from physicians looking for this education, specifically in billing and coding," he asserts. "We have not provided that as an industry, and we have not provided that through our compliance programs."

Belton underlines the cost of that confusion by pointing to estimates made by the Health and Human Services’ Office of Inspector General earlier this year that the cost of physician documentation errors topped $3 billion. Roughly half that amount ($1.51 million) was due to incorrect coding, while another $656 million was due to insufficient documentation, and $432 million was attributed to no documentation.

By contrast, only $291 million was attributed to noncovered services, and $112 million to lack of medical necessity. Belton says one tactic to combat that lack of awareness among physicians is to focus on the risk and personal liability physicians confront on a local basis. "Look at those areas where local physicians are either running afoul of the law or have a situation where there is some type of non-compliant activity," he advises. "That will hit home a little bit harder."

When it comes to integrating physicians, Belton argues that hospitals should seek to capitalize on familiarity by starting with the existing structure within the hospital. That means looking at how the medical staff structure is set up organizationally and strategically evaluating where physicians are involved in the process. By contrast, he says, the biggest mistake hospitals can make is to create a new compliance department and allow it to function as a separate silo department that is not integrated with existing departments.

While most physicians are not yet familiar with compliance, they are familiar with risk management, quality assurance, medical chart review, and accreditation standards, notes Belton. For example, he points out that physicians have always been concerned with quality of care, an area that the False Claims Act is now flirting with. "What you want to do is dovetail with existing committees and subcommittees that are hospital-based."

Belton says that utilizing the existing medical staff structure also means making presentations to the medical ethics committee and recruiting the head of the medical staff as a member of the compliance committee. The next step is to establish regular physician presentations that reinforce a consistent message, he says.

However, Belton says those presentations are more effective as concise 20-minute sessions rather than marathon sessions that combine specialists. "Be careful about having an internal medicine specialist sitting next to a cardiologist or trying to mix your specialties because it won’t work," he asserts. "A cardiologist will want to hear from a cardiologist."

Sometimes external physician consultants can assist in that area. However, Belton warns that external specialists are often difficult to identify, and using consultants that lack genuine expertise can actually rob a compliance program of its credibility. "I have very great difficulty finding a radiologist that can come in and talk to radiologists about interventional coding," he reports.

Belton adds that hospitals should utilize the most recent profiling data that identify coding patterns. He says hospitals must capitalize on information that shows physicians how data are being collected and why they are at risk. Sometimes, that can even include examples of auditing tools used by the local carriers, he adds.