The Office of Inspector General (OIG) found errors
in thirty percent (30%) of all 1996 claims paid by the Health Care Financing
Administration (HCFA). Errors ranged from inadvertent mistakes to what
was determined to be outright fraud and abuse. Rooting out fraud and abuse
has become a high priority of the Clinton administration as a means of
decreasing Medicare costs and the budget. To aid in the close scrutiny
of health care institutions, significant dollars have been made available
to investigators and prosecutors through the Health Insurance Portability
Act of 1996, signed by the President in August of 1996. As HCFA has reported
a $23 recoup for every dollar spent on investigations, it is unlikely that
we will see anything but an increase in audit activities.
Providers who, upon review, are not found to be in compliance with fraud and abuse laws have often been required to implement a comprehensive compliance program to monitor and remedy faulty billing practices. However, under the Sentencing Guidelines, institutions who have implemented an "effective program to prevent and detect violations of the law" are treated more favorably than those without any program. As a result of the Sentencing Guidelines, many health care organizations, large and small, are in the process or have completed the process of designing and implementing a compliance program.
Are Compliance Programs Necessary for Small Organizations?
The benefits of a compliance program for a large organization are certainly apparent given the large penalties experienced by a few large academic medical centers. But, does it make sense for a small organization to invest tremendous dollars, staff time and energy? We believe that one must approach the plan for a compliance program with rational thinking, that is, the program should reflect the volume and complexity of the institution. We further, believe that small is not a ticket for reprieve. In a recent case in 1996, an Ophthalmologist was co convicted of Medicare fraud based on his billing practices even though there was a lack of evidence that he was involved in the billing practices or even aware of how they were handled. Nonetheless, he was found guilty when the court held that individuals could be found guilty if they "adopted a willful blindness".What Next?
Health Systems Management Network can assist in all phases of establishing a compliance program including identifying appropriate leadership through full program implementation.HSMN services would typically include:
- A thorough review of the Hospital's current level of compliance in key areas
- Review of the charge master
- Coding and documentation practices review
- Inpatient and outpatient coding validation audit
- A review of the medical record against the bill.
- Clinical documentation reviews to determine how well documentation supports the bill
- "Short stay" billing appropriateness review for observation and inpatient cases
- Denial review to identify potential problem areas.
- Review billing/system practices for inpatients admitted within 72 hours of outpatient service.
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