By Laura Lovett, CPC, CPMA, CPC-I, CANPC, CEMC, Data Integrity & Compliance Consultant, The Rybar Group, Inc.
As hospitals have acquired a growing number of physician practices in recent years, they’ve also acquired new compliance problems that often fly under the radar. There is a dizzying array of rules and regulations with which healthcare providers must be compliant, and claims submissions are among the most imperative and problematic.
These compliance activities are often more “routine,” and therefore don’t always get the time and attention they deserve. But the problems that can arise when things go wrong can have a significant impact on your organization. Documentation matters for everything from facility claims to the medical necessity for supplies and testing. There are two mind-sets to achieving proper compliance for physician practices: the more proactive “well visit” approach or the reactive “sick visit” approach.
The Well Visit Approach
Just as patients are encouraged to see their physicians routinely for well-care visits, claims must receive regular checkups during the good times, as well, to ensure all services are being performed, documented, coded and billed correctly. If a problem is identified, appropriate actions can be taken immediately to correct it and treat the issue. The process also serves as a tool to keep the staff up-to-date on pertinent guidelines and regulations that affect them and their jobs. While there may be conflicting views on the efficacy of well care for people, there is no doubt to the efficacy of a well-crafted and implemented compliance plan. They work, if you allow them.
The Sick Visit Approach
All too often, it’s the problem visit that we see not only in the treatment of our patients, but also in dealing with various compliance issues.
With the implementation of higher deductibles and copays, we are seeing more patients delay dealing with problems until they have multiple issues, which become more complex when they finally do present for treatment.
The same can be said of compliance issues. Many providers operate under the false impression that since their services were paid, their coding is correct. This is a common misconception in healthcare. It’s true that a paid claim means no issues were triggered by the payer, but that doesn’t mean you don’t have a coding accuracy problem.
Some insurance carriers are more diligent about providing clear written direction around reimbursements, but ultimately it’s a healthcare provider’s responsibility to understand its business operations, the law and the importance of monitoring compliance.
Urgency is of the Essence
Between reimbursement decreases, increases in regulatory requirements, and the general overworked nature of the healthcare industry, healthcare providers are becoming “sicker” and the problems more complex as compliance issues are left to linger. And too many organizations are seeking treatment when it’s too late.
The government is becoming more aggressive in targeting fraud. The Affordable Care Act (ACA) included language requiring that provider practices have compliance plans as a condition of enrollment with the governmental payers. 1 As of the publication date of this article, the government has not defined what must be included in that compliance plan, or the official effective date by which providers must comply; what is clear is that they intend to take a more preventive approach to fighting abuse versus the traditional retrospective pay and chase model.
An active and effective compliance plan is essential to detecting and correcting errors before they become ingrained, complicated issues that eat up precious time and resources to resolve. Implementing cost effective processes may be a challenge, but the financial impact of the consequences can be much more significant. An ounce of prevention really is worth a pound of cure.
1 The Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148), Section 6401: Changes to Medicare and Medicaid Provider and Supplier Enrollment Process
Laura Lovett is a Data Integrity & Compliance Consultant for The Rybar Group, specializing in the area of Professional Service Coding, Auditing and Education. She can be reached at at llovett@therybargroup.com
This article originally appeared in BDO USA, LLP’s “BDO Knows Healthcare” newsletter (Winter 2015). Copyright © 2015 BDO USA, LLP. All rights reserved. www.bdo.com