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Most physician-related government investigations are not triggered by carrier or intermediary audits, but by complaints made by employees or competitors, says Dan Roach, vice president and corporate compliance officer for Catholic Heath Care West in San Francisco. "Every investigation that I have been involved in at two large health care settings has been the result of somebody going to the government and complaining about conduct within the organization," he reports.
Expect that trend to continue. Marc Raspanti of Miller, Alfonso & Raspanti in Philadelphia, says there’s been a 100% increase in the number of physicians who are willing to blow the whistle on hospitals, competitors, and HMOs. "Physicians are tired of being beaten up, and they are increasingly willing to fight back," he asserts.
According to Roach, individual physicians and health systems that employ them can dramatically reduce their exposure if they understand that fact and establish effective mechanisms that address employee concerns, perform basic audits, and promptly refund overpayments. Even modest efforts at compliance will reduce qui tam suits, agrees Raspanti, who is one of the most successful qui tam attorneys in the country. "Ignoring the problem is no longer an option," he warns.
Debbie Troklus, a manager with Price WaterhouseCoopers in Louisville, KY, says a risk-based assessment conducted by the practice often will identify other areas that are high risk and need policies developed to minimize that risk.
Like Roach, Troklus says the best place to start is the OIG’s guidance for physicians and small practices. "That gives several hot areas that should guide you in risk assessment and policy development," she asserts. "The guidance identifies risk areas for both billing and coding."
"A few policies and procedures that I would suggest are record retention, credit balance, nonretaliation/nonretribution," adds Troklus. "Developing policies and procedures should be a fluid process and could save your practice a lot of needless mistakes."
Here are several areas Roach says doctors and hospitals should focus on:
s Documentation. Roach tells physicians the three most important things are documentation, documentation, and documentation, with specific attention focused on basics such as making sure that legible medical records include the reason for the encounter, diagnostic test results, and plan of care, as well as the date and a legible identity including signature.
None of that is new to physicians, and they often get tired of hearing the same message, he warns. But once they understand the implications that documentation has on payment and quality of care reviews, they begin to understand its importance, he adds.
For example, Roach says patients now visit numerous web sites to gauge the quality of hospital services in specific areas such as oncology and cardiac care. "Physicians should understand that minor changes in behavior can make a real difference in how they fare and that documenting complications and comorbidities can have a real impact on how the hospital scores," he explains.
s Anti-kickback. "This is the year of the kickback investigation," predicts Raspanti. He says that means doctors should re-evaluate their interaction with pharmaceutical companies and ancillary service providers, or else they may find that what was common practice not long ago is now perceived as criminal.
Roach agrees that physicians often fail to understand this area, even though kickbacks are covered by the OIG guidance. "The guidance helps them understand that they can be ethical and still not follow the anti-kickback laws," he says.
s Reasonable and necessary services. Roach says another important focus in the guidance is the distinction between tests that a physician might deem appropriate and Medicare’s definition of reasonable and necessary. Even though the OIG attempted to help physicians understand the difference, this remains an area of "substantial confusion" for physicians, says Roach.
s Education and training. Hospitals also can use the guidance as a tool to help support physician education and help physicians understand their obligations. "One thing physicians rarely understand is that there is a federal criminal statute that makes it a crime to fail to disclose overpayments to the government," warns Roach.