Five key questions auditors likely will ask

The right answers can avoid headaches

Here are five key questions federal inspectors often ask when looking at a provider’s reimbursement profile. These are questions your compliance officers also should be asking, suggests Sanford V. Teplitski, head of the health law practice at the law firm of Ober, Kaler, Grimes and Shriver in Baltimore.

1. Do your medical services cost the federal government more than they should? Remember, things like joint ventures designed to capture a noncompetitive market can have the effect of driving up charges to a point where they are higher than those in more competitive, nearby markets. That, in turn, may raise a red flag among government auditors, says Teplitski. To protect yourself, he recommends establishing a set of controls and objective audits to justify your claims.

2. Are you appropriately providing services to patients? Do you give the appearance of overutilizing services for patients you can bill for such procedures? Do you appear to be underutilizing services in cases were reimbursement is fixed? Either can get you into compliance trouble.

3. Is the quality of the care you provide up to community standards? Look for different standards for different payers and whether your physicians and nonphysician providers meet or exceed officially recognized medical quality standards.

4. Is there adequate access to medical care? Check to see if patient access is uniform, regardless of how patients pay, especially when it comes to emergency services. Anything you can do to improve access will be considered a compliance plus. However, any actions that appear to restrict patient access could create a problem.

5. Do your patients have freedom of choice? Be prepared to show that there is informed consent and that patients are free to choose their provider, home health company, radiotherapy institution, etc., regardless of any relationship you have have with those entities.

Also, be prepared to show that patients participate in the decision making when it comes to choosing alternatives between expensive and less expensive treatments or tests. You should be able to demonstrate that patients participate in deciding whether they should go home, be transferred to another kind of facility, or remain for an extended inpatient hospital stay.

Some final considerations when reviewing your compliance efforts include how aggressive you are in repaying overcharges to intermediaries and whether your compliance program ensures disclosure of prior contractual arrangements that may result in inadvertent overpayment by Medicare or duplicate payment by other funding sources.