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Physicians should update compliance plans annually, following the OIG's interest
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:
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:
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.
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.
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. 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.
Betsy Nicoletti is a speaker and practice management consultant specializing in coding education, billing, and accounts receivable, with more than 20 years of experience working with physicians. She can be reached at
(802) 885-5641, email@example.com,
or at firstname.lastname@example.org.
This article originally appeared in the February 2005 issue of Physicians Practice.