Coding and Billing

How to Create an Internal Coding & Billing Compliance Program

By Mark Wright, OD, FCOVD
and Carole Burns, OD, FCOVD
ROB Professional Editors

Nov. 1, 2017

It’s not enough to just submit your claims to third-party “insurance” companies. You must have an internal compliance program to make sure what you are submitting is both true and accurate. Within the Patient Protection and Affordable Care Act of 2010 is a requirement that doctors treating Medicare and Medicaid beneficiaries establish a compliance program.

The question for the day is: what should your compliance program look like? We recommend that the best design of your compliance program is to go to the people who will be auditing you and design your program based on their recommendations. The Office of Inspector General (OIG) is the federal policeman who looks over our shoulder for claims we submit to government programs like Medicare and Medicaid. On the OIG web site is a page called “A Roadmap for New Physicians: Compliance Programs for Physicians.”

The OIG suggests your compliance program contain the following elements:
• Conduct internal monitoring and auditing.
• Implement compliance and practice standards.
• Designate a compliance officer or contact.
• Conduct appropriate training and education.
• Respond appropriately to detected offenses and develop corrective action.
• Develop open lines of communication with employees.
• Enforce disciplinary standards through well-publicized guidelines.

To understand what should be included in each of the seven elements of the compliance program go to the document published in the Federal Register called “OIG Compliance Program for Individual and Small Group Physician Practices.” This document lays out in detail what needs to be included in each element.

Here’s a short quiz over the seven elements to see how many of them you have incorporated in your practice:

Yes or No: Do you audit at least annually a minimum of five records per doctor per third-party carrier from start to finish for compliance?

Yes or No: Do you have written standards and procedures designed to reduce the prospect of erroneous claims and fraudulent activity by identifying risk areas for the practice in coding and billing?

Yes or No: Have you in writing designated a compliance officer with the responsibility of developing a corrective action plan and overseeing the practice’s adherence to that plan?

Yes or No: Have you in writing designated a person in charge of at least annual training for staff and doctors for compliance in coding and billing?

Yes or No: Have you developed a written system within your practice to detect warning indicators such as: significant changes in the number and/or types of claim rejections; correspondence from carriers challenging the medical necessity or validity of claims; illogical patterns or unusual changes in the pattern of CPT–4, HCPCS or ICD–10 code utilization; and/or high volumes of unusual charge or payment adjustment transactions?

Yes or No: Have you established a clear ‘‘open door’’ policy between the doctors, compliance personnel and practice employees, so all doctors and practice employees, when seeking answers to questions or reporting potential instances of erroneous or fraudulent conduct, should know to whom to turn for assistance in these matters without fear of retribution?

Yes or No: Have you incorporated measures into your practice ensuring that practice employees understand the consequences if they behave in a non-compliant manner?

If you answered “No” to any of the questions above, then take this week to fix that problem.

To maximize the benefit, as you fix your compliance program, make sure it exists for all third parties your practice deals with, not just federal programs.

References
i. https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
ii. https://oig.hhs.gov/compliance/physician-education/05compliance.asp
iii. https://oig.hhs.gov/authorities/docs/physician.pdf

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