Practice Management Alert

Come clean quickly to keep your internal audit results from sparking an outside investigation

When you find evidence of over-coding after you've been paid, you need to disclose this information to the appropriate carriers in a way that proves you are honest and had no fraudulent intent.
 
Danger: The jeopardy you face is that the carrier may not believe you, says Elliot Oppenheim, MD, JD, LLM Health Law, CEO and president of coMEDco Inc. in Santa Fe, N.M. And if a carrier suspects that your coding problem was more widespread than you say, it could decide to do a more extensive audit and investigation to try to discover more overpayments, he adds.
 
Solution: "Candor, honesty and being forthright win the day no matter where the chips fall," Oppenheim says. The worst thing that can happen is the carrier telling you to pay the money you owe them, because as long as you are honest you'll make it clear there was never any criminal intent to defraud. Proof of No Intent Is Paramount Carriers draw the line for fraud and abuse charges where they see evidence of intent to benefit by incorrect coding and billing. So in all of your communications to carriers during a disclosure, you want to show that your errors were due to ignorance or poor data quality - "not an issue of intent," says Curt Udell, CPAR, CPC, CMPA, senior advisor with Health Care Advisors Inc. in Annandale, Va. If you create a good impression with your honesty, carriers are more likely to accept what you say without dispute. 
 
Also: You must articulate clearly to carriers why the coding errors happened in the first place, and outline step by step what you've done to correct the problems and prevent them from happening again, Udell says. For example, you might explain how you'll perform ongoing monitoring of the problem area, and how you'll check this issue during your semi-annual reviews, he says. Remember 3 Expert Disclosure Tips 1. Determine the severity of your coding problem before charting your disclosure course. Look at the frequency and revenue volume for the codes in question to decide whether the problem was isolated to a few random mistakes or whether it represents a larger compliance risk for your practice, Udell says. 
 
You must disclose any audit-revealed coding errors, no matter how small, but you should definitely recruit an attorney's help for medium- and large-scale errors.

2. Secure attorney-client privilege. If you decide you need an attorney to ensure the most legal protection during your disclosure, make sure you obtain attorney-client privilege (a standard agreement that guarantees you legal privacy in discussing coding errors with your attorney), Udell says. 
 
The attorney will then help you coordinate a more extensive investigation [...]