Compliance Plans:
Compliance Plan Will Help FPs Through Medicare Audits
Published on Mon May 01, 2000
A central focus of Medicares campaign in the upcoming year will be compliance within solo and small group practices, according to Kimberly Brandt, senior counsel with the Office of the Inspector Generals (OIG) Civil Recoveries Branch. She says OIG is drafting a model compliance plan that will emphasize 12 areas that have been identified as particularly problematic with small practice groups, family practices:
1. Kickbacks;
2. Routine waiver of co-payments and deductibles;
3. Billing for services not rendered;
4. Upcoding;
5. Unbundling;
6. Double-billing;
7. Billing for physician services rendered by
non-physicians;
8. Medical necessity;
9. Misrepresenting diagnosis to justify services;
10. Completing certificates of medical necessity for
patients not personally or professionally known by the physician;
11. Billing Medicare or Medicaid for investigational
research, medications and/or procedures without proper authorizations; and
12. Billing for a noncovered service as if covered.
Compliance Plan Saves Moneyand Headaches
The most effective response to Medicares focus on small practices is to develop and follow an internal compliance plan, advises Thomas A. Kent, CMM, president of Kent Medical Management in Dunkirk, Md., who has worked with national medical centers on compliance issues.
Its not difficult, but it can save any family-practice group a lot of headaches, he points out. A compliance plan can be as simple as a short booklet that describes the billing process in your office. According to Kent, components that should be addressed and clearly outlined include:
Which individuals handle the billing process;
What responsibility each assumes in the process;
Who reviews claims that have been denied by
Medicare;
What system is in place to track denials and identify any patterns that indicate errors;
How denial patterns, errors or problems are
communicated to office and medical staff; and
What system is in place to correct problems and
ensure the situation has been resolved.
It is my firm belief that most family practitionersand the majority of other physiciansare very honest, Kent says. Many of the compliance problems arent conscious attempts to defraud the government. They result when someone is documenting or reporting a service incorrectly and isnt aware of it. Unfortunately, when it comes to fraud, the government does not have to prove intent. They only have to show a pattern of noncompliance.
A well-thought-out compliance plan, he adds, indicates that a family practice has made a good-faith effort to comply with national Medicare and local carrier requirements. If you have a plan in place and can demonstrate that you abide by it, it will help you minimize any penalties in case Medicare conducts an audit and finds problems.
Communication and Education Key to Compliance
Another effective strategy, Kent says, is to emphasize educational programs that keep medical and office staff abreast of coding and compliance issues. Obviously, everyone [...]
