OIG COMPLIANCE GUIDANCE FOR PHYSICIAN

PRACTICES

Washington County Hospital Association, Inc.

CME Program

October 26, 2000

SCOPE OF PHYSICIAN COMPLIANCE PROGRAMS

Promotes adherence to and better understanding of complex rules

Covers Federal health care program claims

Programs are strictly VOLUNTARY Recognizes staff and resource

limitations of smaller physician groups

BENEFITS OF PRACTICE COMPLIANCE PROGRAMS

PATIENT CARE COMES FIRST! Patient care may be enhanced due

to focus on better documentation Minimized billing mistakes can

speed and optimize payment of claims

Reduce chances of a HCFA/OIG audit of the practice

BENEFITS OF PRACTICE COMPLIANCE PROGRAMS

“PREVENTIVE MEDICINE” FOR YOUR PRACTICE

Avoid conflicts with anti-kickback and self-referral issues

Sends important message to staff Shows your patients that you are

making good faith efforts in billing

ERRORS VS. FRAUD?? OIG believes most

physicians are honest and provide high quality care

Cannot be penalized for innocent errors or even negligence

Fraud is reckless or intentional conduct

AUDITING AND MONITORING

MONITORING Monitor coding

patterns Review practice

billing procedures Review claim

submission process Review a sample of

chart documentation

AUDITING AND MONITORING

AUDITING Conduct detailed review of 5-10 charts

per physician for Medicare and Medicaid patients from notes to claim payment

Look at coding, documentation, medical necessity and possible incentives

Creates a baseline for comparison after compliance program implementation

PRACTICE STANDARDSAND PROCEDURES

Coding and Billing Reasonable and

Necessary Services Documentation in

the medical record and on bills

Inducements, Kickbacks and self-referrals

CODING AND BILLING Claims for services

not medically necessary

Duplicate billing Billing for items or

services not provided

Billing for non-covered services as if covered

Misuse of provider identification numbers

Unbundling Failure to use

coding modifiers Clustering Upcoding

THE “REASONABLE AND NECESSARY” DISCONNECT OIG says

physicians may order any tests they believe are appropriate

BUT . . . Medicare only pays

for services they define as “reasonable and necessary”

SO TO GET PAID . . .

Become familiar with carriers’ LMRP (Local Medical Review Policies)

Issue ABNs to patients when appropriate, or you will NOT be paid

PRACTICE COMPLIANCE OFFICER OR CONTACT

Need NOT add staff Can divide various

responsibilities Can outsource or

co-op function with other practices

Final responsibility rests with the physician!

TRAINING AND EDUCATION

LOTS OF OPTIONS Seminars and

classroom sessions Newsletters Office bulletin

board Free Internet-

based courses WCHS offerings

RESPONSE TO PROBLEMS—

CORRECTIVE ACTION Investigate and

correct apparent infractions promptly

May require some repayment to gov’t. – don’t try to hide

Remedial training may be sufficient

Ask for help

COMMUNICATION An “open door”

policy with practice staff is wise

Bulletin board notices and “pass-around” memos are useful and inexpensive

Ask for input

DISCIPLINARY ACTION Actions must have

fair consequences Review proper

procedures and require additional or repeat education

Do keep records of personnel actions

OTHER RISK AREASREASONABLE &

NECESSARY SERVICES

LMRP ABNs Certifications for

DME and Home Health

Billing for non-covered services

PHYSICIAN RELATIONSHIPS WITH HOSPITALS

EMTALA Teaching physicians Gain sharing Incentive

arrangements Medical

directorships

OTHER RISK AREAS

BILLING PRACTICES

Third party billing services

Non-participating physicians

Professional Courtesy

MISCELLANEOUS IDENTIFIED RISK AREAS

Rental of office space to parties to whom you refer

Unlawful advertising

HIPAA regulations

GUIDANCE ALSO INCLUDES

Summary of Criminal Statutes Listing of Civil and Administrative

Statutes OIG-HHS Contact Information Carrier Contact Information

Trailblazers Health Enterprises – Part B Internet Resources for practices

QUESTIONS OR COMMENTS? Shana Wolfe,

Washington County Health System Compliance Officer

Pangborn Hall, 403 301-790-8878 ComplianceLine

888-847-9247

THANK YOU!