Medicare Compliance & Reimbursement

Government agencies and auditors are on a roll in pursuing what they view to be inappropriate healthcare utilization. And that means physicians and physician practice groups might be wise to give their practice patterns a check-up.

Physicians should understand how their practices "relate to the prevailing standard of care in their geographic location and nationally," advises attorney Jason Caron, with Epstein, Becker & Green in Washington, D.C. Making that effort isn't important just for the sake of federal compliance, he adds. It "relates to a host of other issues, including potential reputational and malpractice issues."

Using this approach, "the organization can make informed decisions" about how they stack up "relative to their peers and can ... either adjust or curtail certain practices or support their legitimate clinical reasoning  behind practice patterns that may fall outside the norm," says Caron.

A few smart moves can keep auditors from your doorstep or send them packing in short order if they do question your practice.

1) Use specialty practice guidelines as a benchmark. Physicians should compare their practice against their latest specialty clinical practice guidelines, which spell out diagnostic and treatment best practices, advises John Shershow, MD, a consultant in Long Beach, N.Y. "Using the guidelines as a benchmark" -- it's pretty hard to go wrong, he says.

2) Examine and explain outlier practices. Physicians don't use guidelines "in a cookbook or slavish way," Shershow notes. Sometimes physicians face "an unusual variance in the way patients present or respond to treatment. The guidelines take that into account, allowing for variation," he says.

That being said, "if an individual physician within a practice appears to be an outlier," that's a "red light" to take a look, Shershow stresses. "It may turn out that what the physician is doing is completely appropriate," he says. For example, perhaps the physician cares for a higher-risk population or patients requiring more aggressive or frequent care.

Another possibility: A physician may be a clinical innovator in a particular area, says Caron. And that can "often involve more risk" because the clinical evidence and payer standards haven't yet evolved. Or perhaps a physician has taken a particular position on a clinical issue in an area where experts disagree about the best approach. "There is often robust discourse among clinicians about standards of practice -- look at all the differences in views that recently surfaced related to mammogram guidelines."

3) Compare care for different populations with the same conditions. Physicians also have to be aware of reimbursement requirements and how their ordering patterns for various payers shake out. For example, some third party payers get "pretty aggressive" in doing preauthorization for diagnostic services, observes attorney Christopher Lucas, in private practice in Camp Hill, Pa.And you want "to make sure different groups of patients don't have significant differences in how they are treated due to third party payer pre-authorization. That'd be a major red flag for Medicare," warns Lucas, noting that Medicare could access the information from the third party payer or from the physician.

(Editor's note: See the related article on hospital peer review programs, page 26.)