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Time to Take Back Control of Healthcare


Coder Emily Hill talks back about fraud and abuse prosecutions and undercoding

Over the years, I have had the opportunity to speak at a variety of medical conferences on issues related to coding, documentation, and compliance. Each time I am amazed at the number of physicians in attendance - at the expense of participation in clinical programs. This really should come as no surprise; everywhere I go, I find physicians afraid of making coding mistakes that they believe will result in fines, penalties, and possible jail time. I often joke with my audiences about their paranoid state of mind. They used to laugh; now they stare back as if the statement itself might be some sort of setup. The result of this anxiety is that many physicians have decided that the easiest approach to billing is the path of least resistance: to undercode, and bill for less, rather than report the right code and get it wrong.

In a ‘fix’?

It’s easy to see how physicians got to this point. A few years ago, the Health Care Finance Administration (HCFA) began a campaign publicizing the amount of overpayments due to improper coding, inadequate documentation, and other errors. As part of the “fix,” HCFA solicited beneficiaries to report their physicians if they believed a claim had been falsely submitted. The press had a great time with all of this, and physicians became targets of suspicion in the public’s eye. I even had a resident - who was clearly having second thoughts about his chosen profession - ask me if I believed most physicians were dishonest. Add to this situation the frequent revisions to the Evaluation and Management (E&M) Documentation Guidelines and the auditors who viewed them as “rules” instead of “guidelines.” Suddenly, physicians found themselves having to justify their approach to care to reviewers who lacked clinical background.

And let’s not forget the Office of Inspector General (OIG) and its heavy-handed approach to perceived healthcare fraud and abuse. Along with this strategy came compliance programs and such phrases as “federal sentencing guidelines,” “false claims,” and “deliberate disregard.” Even the acronym OIG has found its way into common medical lingo. And now third-party payers are deciding to reduce E&M levels of service without questioning the physician or reviewing medical records. Maybe physicians are right: It certainly seems easier to downcode. And what a great deal for payers. Their customers (the patients) continue to receive medical care without a financial impact.

The real crime

But hear this. Although the concern about overcoding is being addressed on the one hand, physicians in general are not addressing the dangers of undercoding, despite the warnings of some consultants. But “danger” might be misleading. Regardless of all the rhetoric about undercoding being a crime, I haven’t heard of anybody going to jail for it. Instead, there are physician practices unnecessarily spending lots of money on consultants and compliance plans, while worrying about how to pay the electricity bills for their offices. And that is the real crime.

A few months ago, OIG expressed to the Practicing Physicians Advisory Council (PPAC) its concerns about the degree to which undercoding is occurring and the number of physicians who have dropped out of the Medicare program because of the fear of possible investigation. Apparently, this is not the end result that the government’s fight against fraud and abuse was supposed to produce. However, at the same meeting, OIG acknowledged that it has received increased funding for more audits and investigations. With all the conflicting pronouncements, it’s no wonder that most healthcare professionals are confused.

Perhaps it’s time for physicians and other providers to take back control of the healthcare system. After all, it shouldn’t be a crime to provide good patient care and to bill for appropriate services. When physicians undercode, they are distorting the true cost of healthcare. The best approach may be to fully document services, take responsibility for appropriate coding actions, and allow the full financial impact of patient care to be assumed by those who profess to pay for it.

Emily H. Hill can be reached at editor@physicianspractice.com.

This article originally appeared in the March/April 2001 issue of Physicians Practice.

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