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). The OIG 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.
Update your plan with OIG's
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.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.
- You have added services or providers.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.
- "Frequent fliers" on the 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.
Getting started on this year's plan
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. 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.
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.