Lisa Kohler, MD - AkronCantonMDNews

legal ease
Expecting Inspection
By Cathy A. Sloane, Esq.
The physician’s day in the office was
going fairly smoothly until the practice
manager announced an unexpected visitor;
a Medicare auditor was seated in the
conference room. When asked if there was
a problem, the auditor gave no specific reason
prompting this surprise visit. Rather,
she explained that she would be auditing
patient charts for adequacy of documentation
on claims billed to Medicare. The
on-site inspection of records would
begin today.
This is a fictional story, but it illustrates
the discomfort that physicians face when
surprised with an audit from an insurance
carrier. The questions are many. Is
this a routine inspection? Have there
been patient complaints? Has the medical
practice been flagged by irregular billing
patterns? Worse yet, could this be a
whistle-blower investigation?
Although an external audit can certainly
be random and routine, physicians are
acutely aware that Medicare and other
insurance carriers often conduct audits to
investigate suspected fraud or abusive billing
practices. Physicians cannot avoid all audits
like this one, but there are actions that you
can take to decrease that probability.
AUDIT PREVENTION
The Department of Health and Human
Service and the Office of Inspector General
(OIG) have asked physicians to voluntarily
develop and implement compliance programs.
A compliance program integrates
the various complex laws and regulations
into your claims-processing procedures.
Ideally, the goal is to prevent fraud and other
wrongful behavior.
A comprehensive compliance program
will include a coding compliance policy.
Although an external audit can certainly be random
and routine, physicians are acutely aware that
Medicare and other insurance carriers often conduct
audits to investigate suspected fraud or abusive billing
practices.
This policy is a “meeting of the minds”
between the physicians, billing staff, and
insurance carriers that claims will be
processed with agreed values (codes).
Importantly, the coding compliance policy
should establish a plan for both the internal
monitoring and independent reviews of
your coding and billing functions.
Internal monitoring is your day-today
assessment of operations to ensure that
processes are working as they are intended.
For example, internal staff with coding
expertise might routinely monitor a sample
of records for “evaluation & management”
(E&M) coding accuracy. The frequency and
type of internal monitoring will vary based
on the dynamics and specialty of the practice.
Staff should not forget to document their
monitoring activities according to policy.
Independent reviews are chart audits
conducted by a certified coder at the
request of the physician. Too often overlooked,
independent reviews are vital to
your compliance program in that they are
non-biased, external controls for assessing
any weaknesses in your coding and billing
processes. Should an investigative audit by
an insurance carrier later reveal inaccurate
coding, the independent review by a certified
coder can demonstrate your reasonable
efforts to comply with ethical and legal
business practices and thus avoid a fraud
claim basis.
Physicians are advised to schedule an independent
review with a certified coder at
least annually. Independent reviews should
be scheduled more frequently if there have
been significant additions to the medical
staff, changes in documentation methods,
or increase in rejected claims.
CONCLUSION
Insurance carriers have become stricter
in enforcing accurate coding and billing
as substantiated by documentation in the
patient record. Random audits are not
uncommon. However, physicians can take
steps to minimize the likelihood of a payer
audit, and mitigate possible sanctions, by
establishing a compliance program.
An effective compliance program will
lessen the risk of fraud and abuse by identifying
and addressing high risk areas.
Self-monitoring and scheduling an independent
review by a certified coder are
compliance efforts deserving of your special
attention. Your healthcare attorney can
locate a coding specialist familiar with your
practice needs.
NOTE: This general summary of the law
should not be used to solve individual problems
since slight changes in the fact situation may
require a material variance in the applicable
legal advice.
Cathy A. Sloane is a Nurse Attorney
and Certified Coding Specialist Physicianbased
with the law firm, K rugliak,
Wilkins, Griffiths & Dougherty Co., LPA
in Canton. ■
GREATER AKRON/CANTON M.D. NEWS JANUARY-FEBRUARY 2008 | 35