Medicare Compliance & Reimbursement

Identify practice risk areas.

Increasing scrutiny by the HHS Office of the Inspector General (OIG), Medicare, Medicaid and other federal and state healthcare programs as well as private payers means that you need to curb the rise in medical costs and run your business more effectively and efficiently. An annual review of your practice’s performance can help keep your business running smoothly.

Give Your Practice a Check-Up

Part of running a successful business is to develop an annual business plan that sets goals, strategies and performance expectations. The first step is to analyze your business and assess what goals were or were not accomplished in the previous year, and review strengths, weaknesses and areas that need overall improvement.

It’s essential to give the practice a good physical exam each year. A risk analysis should encompass every aspect of the business because almost everything can affect compliance. For example, reviewing personnel issues is important because the practice needs to make sure that none of the new hires, or existing ancillary service providers used by the practice, are on any federal or state sanction lists. It may be stated in the practice’s policy manual that employees must disclose if they are on a sanction list, but it is the responsibility of the business to check annually.

Note: The OIG 2013 Excluded Individuals/Entities list is on the OIG Web site at oig.hhs.gov.

A good risk analysis is the ultimate in preventive medicine for a practice. A proper risk analysis will help increase profits because good evaluations should lead to better performance. When conducting a risk analysis, you need to be thorough, even seemingly minor issues can take a toll on your bottom line.

For example: Be sure to look at the magazines in the waiting room to see how old they are. This tells you how a practice takes care of the front end of a patient’s visit. If the magazines are three years old, then it’s apparent that patient/customer care is not a priority. Patient care starts from the moment a patient comes in and continues to the minute they leave, and, if the patient is referred, even further.

When you review your office carefully, you’re likely to find ways to increase small aspects of documentation that can raise revenue considerably. Investigate whether your practice falls into the trap of over-providing services, under-documenting what was provided and coding somewhere in the middle.

Keep Your Backyard Safe

The biggest issues that alert the enforcement agencies about any practice are when there is no active compliance plan in place and no proactive compliance officer. Be sure to also monitor the following:

• Review areas of the practice that have a history of needing improvement.
• Review high denials for certain codes or modifiers.
• Check for documentation problems, such as legibility and completeness.
• Adhere to the “the coding triangle” — Does the code match the diagnosis? Does the diagnosis match the documentation? Does the documentation match the code?
• Review the utilization profile to see how your practice compares in the geographic area. If the practice is on the high side of the comparison, review the documentation to make sure it meets the requirements for that code. Be aware that if the practice is out of profile on either end of the scale it will arouse suspicion and scrutiny, so see if coding needs to be corrected.
• Complete a paper audit by reviewing all the practice’s forms to see how they are being completed or whether they need to be updated because of new regulations. This should include the new patient form, encounter form, explanation of benefits, certificate of medical necessity, advance beneficiary notice, etc.
• Find out where the Centers for Medicare & Medicaid Services (CMS) is heading by reviewing the OIG Work Plan, legal opinions, fraud alerts, audit reports, and the latest compendium of significant OIG cost-saving recommendations that have not been fully implemented. Full implementation of the recommendations could produce big savings for your practice.

Identifying risk areas in a practice is a matter of knowing where to look for the items that invite scrutiny. Once you complete your review and correct the problems, the rest of the year should go smoothly.

Tip: Due to the time involved, it may be best to hire a compliance consultant familiar with risk analysis to do a review. That will give you a good indication of where your practice stands.