Q: I would like to start implementing a compliance program in my integrated practice. How do I start?
A: Start small. Trying to implement a full compliance program in one stroke will most likely result in frustration, confusion and ultimately failure (and a tendency to avoid the situation). Do not buy a pre-packaged compliance program.
Start by doing an audit of your practice. Such an audit will not only help your practice prevent billing errors but it will also support the billing-related elements of your practice’s compliance plan and help to demonstrate a good-faith effort at compliance to any enforcement personnel if your practice is ever investigated.
The scope of the audit
- All billing, claims processing and reimbursement procedures and practices (“billing”) should be audited internally on a quarterly basis under your direction. You can designate someone to help but that person should be knowledgeable concerning billing. These internal audits should consist of a review of selected internal billing, claims processing, and reimbursement matters. Determine the areas on which the audit will focus. For example, one quarter might focus on a particular provider, another quarter might focus on a specific payer, and a third quarter on a specific code that is being billed.
- On an annual basis, conduct an audit of all billing, claims processing and reimbursement procedures and practices under the direction of your practice’s attorney. These audits may focus on—but are not limited to— claims processing and submission, government billing, reimbursement matters, and secondary payer issues. Initiate additional audits if you find errors.
- Analyze the top 20 CPT codes for percentage growth on an annual basis. If a review of CPT codes shows a growth rate of more than 10 percent, confirm the reasons for such an increase. Any discrepancies or issues should be directed to your attorney.
- If any audit findings indicate your practice may have been paid for claims incorrectly, promptly repay any amounts due and owed to payers (but first consult with your attorney).
- Amounts determined in the ordinary course of your practice’s operations to have been paid incorrectly should also be returned to payers on a regular basis.
- Routinely provide your employees with relevant information received by your practice from any third-party payers regarding the submission of claims.
- Contact your practice’s major payers to determine what the time limits are for filing claims then post a chart containing those limits on a wall in the billing area.
- Check your billing software to determine if it contains edits that prevent simple claims errors, such as invalid diagnosis and procedure codes, sex/ diagnosis or sex/procedure conflicts and age/diagnosis or age/procedure conflicts.
- Learn to read payer remittance advice reports. Obtain payer manuals or newsletters to learn why payers are not paying. Each payer has their own cryptic abbreviations for why they have chosen not to pay for a given service; payer manuals or newsletters usually contain a key to these codes—get them.
Keeping up with changes
Review and preserve newsletters, special fraud alerts, and bulletins issued by the insurance carriers that process claims for Medicare, Medicaid and other insurance programs. Such information should also include any such information issued by the federal government and any payer-specific guidelines.
These newsletters, alerts and bulletins are important and often the most easily accessible sources of information about policy and procedure changes that directly affect billing activities.
They can also benefit you by alerting your practice to the need for changes in billing and coding procedures ahead of time, thereby preventing billing errors.
To maximize the benefits of these newsletters and bulletins, do the following:
File all newsletters and bulletins chronologically in a central place, such as a notebook or designated computer file that is known and accessible to all billing personnel and their immediate supervisors.
One person should be in charge of receiving all such newsletters, reviewing them for relevant information, and initiating any required changes in billing and coding procedures. That person should promptly contact carriers about any areas of ambiguity or other relevant questions that such bulletins may raise.
Document your contacts with carriers and file such documentation in the same place as the bulletins to which they relate.
Make sure that all carrier clarifications are disseminated to the billing staff and appropriately reflected in future billing and coding procedures.
After you designate the above tasks to the appropriate staff members, make sure they get done. Conduct regular reviews of your compliance plan because it will need to adapt to changes over time.
If you have questions concerning the above or about any other legal heath care issue, send them to me. Those questions that are of interest to the broadest audience will be answered in a future column.
Deborah Green, Esq., practices law in New York and Florida and has been a practicing attorney since 1977. If you have any questions concerning this article or other legal healthcare issues, she can be contacted at firstname.lastname@example.org.
DISCLAIMER: This column is provided for educational purposes only. The information presented is not as legal advice and no attorney-client relationship is hereby established.