There are countless reasons for CMS to request records to verify the accuracy and documentation of information submitted for payment; their approach is to ‘pay and pursue.’ Nevertheless, mistakes – no matter how innocent – can prompt prepayment review, which becomes a costly and frustrating endeavor for the provider.
Compliance is one of those nebulous, expensive-sounding areas that causes most providers to assume a “Don’t ask, don’t tell” posture. After all, we’ve never met a practitioner whose behavior knowingly straddled the fine line between legal and not. But mistakes do happen, and the best of habits erode over time. Proactive providers of a certain size rely on an established Compliance Program to keep them out of trouble. In our experience, however, practices with one or two providers mistakenly assume they’re too small to be on the radar and lack the financial resources for large-scale compliance activities.
But in the field of compliance, even a little bit is a good start. Here are some basic components you can put in place right now:
• ‘Audit’ is a fancy word for reviewing what’s been done. In order to realize any benefit, audits must be conducted by a knowledgeable individual who is not responsible for the daily work being audited and on a regular schedule. Quarterly reviews allow you to catch mistakes early, remediate behaviors and conduct education.
• The first step is to identify the criteria for review. We suggest a coding audit to launch your compliance activities. Select a sample of billed visits from each provider and review the documentation associated with the claims. Were the visits billed correctly? Timely? Were the proper codes (diagnosis, procedure and modifiers) assigned? Is medical necessity clearly documented? One frequent issue we find is the absence of documentation of venipuncture services performed when the provider checks the venipuncture service on the superbill.
• It’s a good idea to create an audit tool so you can objectively document the findings. Be sure to add criteria based on the coding guidelines for your specialty as well as your internal policies and procedures so you can assess staff compliance with the rules.
• Scoring is an important step so make sure to reduce the answers on your audit to a numeric value. Since 100% is the target, any score under that will prompt some corrective action.
• Corrective action needn’t be a huge burden. Simply identify the areas where your practitioners and/or staff fall short of the requirement and implement steps to remediate their behaviors.
• Education is a key factor in any corrective action plan, in addition to a more heightened re-audit schedule to check for improvement. Your investigation of the errors may also reveal office processes that are absent, broken, disregarded, confusing or contradictory, or a combination of these.
• Be sure to involve stakeholders in the corrective action process and make the changes you need. Quickly.
Finally, compliance work requires a commitment of time and resources. A half-hearted attempt with no follow-up is as bad as having no process at all. A demonstrated commitment to proper coding and billing may minimize any fines or penalties.