By Betsy Nicoletti
From Physicians Practice Inc. In a recent phone conversation with a physician, we discussed the documentation guidelines and the requirement for physicians to comply with either the 1995 or 1997 set of guidelines. At the end of the conversation he asked me, "Could I have been expected to know about these guidelines?" Of course, the answer is yes. The government expects physicians and their staff to know the government regulations related to billing and submitting claims to Medicare and Medicaid -- and the government sets forth their specific concerns and areas of interest each year through the Office of Inspector General (OIG). Congress created the OIG to protect the integrity of services provided by the Department of Health and Human Services (HHS) and the beneficiaries it serves. The OIG has a responsibility to report its findings to the Secretary of HHS and to Congress, and it carries out its duties nationwide through audits, investigations, and inspections. As part of its work, the OIG publishes an annual Work Plan that describes the areas of interest of the OIG's work for the coming year for hospitals, physician practices, home health agencies, and other providers of healthcare. It is divided into about 20 sections; the one that relates specifically to physician practices is "Medicare Physicians and Other Health Professionals." Each year, starting in early October, practices can read this section and adjust their compliance plans accordingly. It can be found at www.oig.hhs.gov/publications/workplan.html. Many practices have a terrific compliance plan -- sitting on the shelf -- that describes their philosophy, commitment to compliance, roles and responsibilities, and how they will respond to a complaint. And it's true that most practices have limited resources to expend in compliance activities. But if you haven't done so lately, it's a good idea to get into the habit of reviewing and updating your compliance plan regularly, in conjunction with the annual Work Plan. In 2000, the OIG released a draft guideline of its recommendations for compliance plans for individual and small group practices, and many practices made an effort to outline their annual compliance plan back then. This draft is still available at www.oig.hhs.gov/fraud/complianceguidance.html. Use the compliance guide as the foundation of your plan, and each year, when the OIG releases its Work Plan, make sure you have done all the activities you committed to do, and revise your plan according to specific areas of interest for the coming year. Why you need to update Here are a few good reasons to regularly update your compliance plan:
* You have not followed your plan; perhaps it was too ambitious.<B>
When you implemented your plan, you may have underestimated the amount of time it would take. The guidance states that practices should audit two to five notes per government payer, or 10 notes per provider. Even if your practice does not see patients from government programs, it is still a prudent idea to review about 10 notes from the payers you bill in your practice. If necessary, revise your plan to a level that is achievable.
* You have added services or providers.
If you have added a new service, consider auditing the billing for that service. Often, new services or new providers are a source of errors.
* Last year's audit showed a specific area of concern.
Focus on areas in which you've had errors. For example, if last year's audit showed that your physicians are accurate with established patient visit coding but have errors in hospital work, audit hospital notes this year.
* "Frequent fliers" on the OIG Work Plan.
Some areas are listed year after year on the OIG Work Plan, including E&M services, consultations, incident-to billing, use of modifiers, tests ordered by excluded physicians, care plan oversight, and long distance claims. Pay attention to any areas that appear repeatedly. The 2005 Work Plan includes some areas we have seen before, some ongoing projects, and a few new ones. The OIG selects topics for the Work Plan that have significantly increased in volume over previous years, that commonly contain errors when billed, and that are confusing for physicians and carriers. In selecting your compliance activities for the coming year, run a procedure report that lists the procedure codes you bill by volume and revenue. Then, make a list that includes:
* All areas on the OIG Work Plan that your practice performs
* Areas from last year's audit that showed errors or lack of understanding
* Issues that you committed to audit per your compliance plan, if any
* Your high-volume or high-revenue procedure codes Pay special attention to any recommendations from last year's audit. Did you implement them? Worse than neglecting to audit your billing and coding is to audit, find errors, write a report showing those errors, and then keep billing and coding incorrectly. Most practices do not have the resources to audit all areas every year. There are patients to see and treat, after all. After you have your list, choose to audit those areas that represent high volume or high revenue to your practice or are the source of the most billing confusion. Assign someone in the practice, typically a certified coder or your billing manager, to research each area. It is important that you know the rules clearly before you begin to audit your work. The next step is to audit your billings for those areas. You may want to involve a healthcare attorney in this step if you are performing a retrospective audit. If your lawyer engages the auditor to do the work, this gives the work product attorney-client privilege, which limits government access to the documents. Some practices hire an external auditor to do the reviews and some practices perform these reviews internally. Larger practices may have the resources to devote to training an auditor, and have sufficient volume of audits to keep the auditor's skill honed. Smaller practices are usually better served by hiring an outside auditor to do the work. Remember, if you find that a government program overpaid you, you are required to refund it. If you find errors, such as level of service errors, you can return these to your carrier by making a voluntary refund. Carriers usually have a form on their Web site to help you do this. If you find more systemic errors, consult your lawyer. For example, if your review shows that a provider did not understand the difference between a new patient and an established patient, and you have reason to believe that the problem was long-standing and repetitive, you may need a different response than a voluntary refund. The final stage of the audit is education. Make sure your staff and physicians are up to speed on all areas of billing and coding on the OIG Work Plan that your practice performs, both low and high volume, even though you may only have the resources to audit selected, high-volume billing and coding areas. Schedule the educational session when you have sufficient uninterrupted time with your physicians and staff. Your compliance plan should not be carved in granite. Adapt and change it to respond to new services you provide, new billing rules, and the areas of interest outlined in the OIG Work Plan each year. Copyright (c) 2005 Physicians Practice Inc. www.PhysiciansPractice.com. All rights reserved. Republication or redistribution of Physicians Practice content, including by framing, is prohibited without prior written consent. Physicians Practice shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. | 
