For Specialized Providers

Developing a Compliance Plan

Until recently many practices especially smaller ones were not overly concerned about a “Compliance Plan” but recent events have indicated that the OIG will go where the money is. HSMN can provide not only a Compliance Plan but help to put into place a regular review to look at the quality of the coding and clinical documentation with corresponding review of the 1500 claim and the eventual EOB. Why is this important? The Practice will not to know if its coding correctly, billing properly, and receiving the appropriate reimbursement.

Unless this is done there is no way of knowing. Should the Practice find they have upcoded or overbilled then self disclosure is critical to maintaining approval to receive Medicare Reimbursement.

The process is straight forward and easy. But the idea of monitoring must become part of “Culture of the Practice” in the coming year and with the Health Care Legislation about to take effect, there will be much closer scrutiny of physician practices. Physicians will begin to experience what hospitals have in the RAC reviews in which the Federal Government has taken back millions of dollars.

The Feds hire companies who receive a commission on the money they find. They always find something. Even if the finding is not justified, the Practice will spend a great deal of time and money trying to get the reimbursement back. HSMN had done many reviews and compliance plans and have found that physicians are more likely to under bill than overbill. As it turns out, under billing is as much of a red flag as overbilling.

Identifying Risk Factors in your Practice

HSMN has found that in a Practice Growth Mode, especially when new clinical partners are being brought on board and are put into the fray of patient care, one very important thing is overlooked. How are they doing with clinical documentation/and/or in the appropriate identification of the proper codes for the service provided? It is important that the senior biller or practice manager carefully the new Clinician’s encounters/procedures to make sure that clinical documentation and the coding match well.

Often this is an opportunity for the new Clinician to bring new information to the billing/practice manager about the procedures they perform and how they have coded in their other assignments. Such a review should be done for the other partners to make sure they are up to speed on documentation and coding. Doing so reduces the risk factors that are now being heavily scrutinized by the CMS and other third party payers. One last observation is that the billing staff and the practice manager need to be brought up to date as well since codes change every year.

Having a hands-on session by an expert coder who has reviewed some of the documentation of all of the partners will help in both the education process and the identification of risk factors.

An annual review is a smart way to go.

Internal Audits

HSMN over a period of 25 years in practice has identified myths in Medical Practice; Myth#1: We are a small practice and the OIG is looking for the big providers or big volumes. False, there are a number of things that will trigger a review either by the Feds or a third party payor. They are embedded in the annual work plan the OIG announces each year. In it you will find that undercoding is a red flag. As well as performing certain procedures bilaterally, and a host of other flags will trigger a review despite the volume. You ask why? Because the Feds want to make an example of anyone who they believe is committing fraud. Most of these findings are misunderstandings but they take a lot of time and money to correct. (Think IRS Audit). So the easy answer is to do your own internal audits and when mistakes are found especially overbilling, they must be reported voluntarily. Then the practice must show they have taken corrective action in the form of monitoring. Sometimes it is best to call in outside experts on a quarterly basis to review cases. A best defense is an offense that anticipates that mistakes are made. Of course in this writing we are not talking about those who have really tried to get away with fraud. We are talking here about the Clinician who is a busy practitioner and sometimes is not perfect in their documentation.

Correction Plans

In previous articles we have talked about the need to do internal monitoring to identify risk factors. These audits and monitoring reveal revenue opportunities because we have found in 25 years of doing this work, most clinicians tend to be conservative about their E&M levels because they think that only the up-coded cases will be identified.

Under coded cases present two great opportunities:

  1. The ability to drive additional revenue that is supported by documentation.
  2. The ability to identify any risk that would make the practice vulnerable.

When both of these opportunities are found, An Action plan should be put into place that assures with some reasonable certainty that on an ongoing basis the “Practice” has addressed and corrected the issue.