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Fraud. Abuse. Compliance. These three words represent issues that are – or should be – of great concern for every type of healthcare provider – including physicians.
The Department of Health and Human Services’ Office of Inspector General (OIG) estimates that about 10 percent of the nation’s trillion-dollar healthcare budget may be misappropriated due to fraud. In the past five years, three acts have been written into law to fight fraudulent and abusive healthcare practices.
The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996, and the Balance Budget Acts in 1997 and 1998. Since their passage, investigations have been rapidly escalating.
It’s important to realize, that all physicians are now the focus of increasing and intense scrutiny – not by just Medicare and Medicaid, but by the entire health insurance industry. Every claim sent to all types of insurance plans must be accurate and complete, or if reviewed, it could present a major problem and result in costly civil penalties.
OIG particularly targets billing practices, reviewing claims for errors (i.e., charging for services not provided, etc.) and upcoding (i.e., not having the documentation to support the level of E/M services provided).
So, what do you do?
First, you perform your own compliance “health check.” Carefully examine all of your current operations, policies, procedures, documentation, and code data, looking for existing and potential violations of the law.
Then, based on your findings, develop, implement, and maintain a vigilant checks-and-balances program that will keep your practice compliant with the laws.
The most important aspects of compliance involve …
- Coding and billing.
- Proof of the need for service. (You must be able to provide documentation that the service was reasonable and necessary.)
- Documentation. (Your documentation must be thorough and accurate.)
- Relationships with others. (This is the area scrutinized for kickbacks, inducements, or self-referrals.)
Initiate a compliance audit by reviewing your practice’s claim development and submission process from the beginning of patient service to submitting a claim for payment. Make sure you have adequate and accurate documentation to support claimed services, procedure codes, and level of service.
Use a chart audit to look at your coding and billing. Your medical records not only should facilitate a high quality of patient care, they also should verify and document precisely what services were provided.
Compliance and chart audits can be very beneficial for your medical practice, whatever its size or type. As accountants and management consultants with exceptional healthcare expertise, BPCD&S can help you prepare plans for these audits, and then assist you with the follow-through to ensure that your practice is being run in accord with the laws, and to assure you that you would be able to withstand any inquiries or audits made by the OIG.
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