Use OIG compliance guidance to stay out of trouble
By Deborah Green, Esq.

The Office of Inspector General has issued “Compliance Guidelines for Small Practices.” As much as I would like to have a formal compliance program, I can’t afford it yet. What do you recommend I do?

The government’s compliance guidance for small practices is one of the most helpful documents issued by the government to keep doctors out of trouble. Until you can fit the entire program into your budget, I suggest you do the following:

• Review your employee manual and make sure it complies with Medicare and your state’s rules and regulations.

• Develop an agenda of the written policies and procedures you plan to implement during the next year.

• Write a policy that describes acceptable conduct for your practice. Make sure it states that there will be no retaliation against any employee who brings a violation or potential violation to your attention.

• Write a basic billings policy that includes a statement that the practice will not submit claims without proper supporting documentation or with falsified documentation, that are medically unnecessary, and that don’t meet “incident-to” supervision requirements if you are performing “incident-to” services.

• Conduct a coding/billing mini-audit of your practice. The way to conduct such an audit is to go back six months and pull 10 charts for a specific date of service.

Ask each member of your staff who is involved in coding and billing to review each chart and have them track the chart through services rendered, coding for the services, the charge slip, the patient ledger, the insurance form, and the EOB received.

If a comparison of the final EOB to the original service and coding shows discrepancies, address them as soon as possible.

Some explanation of benefits forms (EOBs) state that the insurance company is taking discounts “subject to PPO adjustment,” with no additional information provided. How do I handle this?

This type of EOB should be an immediate warning to you that the payor is probably not affiliated with your PPO.

Call the payor and demand proof that it is, in fact, affiliated with your PPO. If the payor cannot supply proof, demand your full payment.

It may be in your best interest to invest in software that permits automatic comparison of what you are actually being paid to what you should be receiving from third-party payors.

Deborah Green is a practicing attorney who specializes in healthcare. She is licensed to practice in Florida and New York. She can be reached at 954-971-7778 or by e-mail at healthattorney@aol.com.

DISCLAIMER This column is provided for educational purposes only. The information presented is not presented as legal advice with respect to any matter and no attorney-client relationship is established.