Steven Baruch - Health Care Compliance Association

December 2010
26
Physician compliance
education outside
of the hospital
environment
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has become one
of the most frequently used
“Compliance”
terms in health care today—
especially within the hospital environment.
Hospitals are faced with ever increasing challenges
of remaining up to date on all aspects
of health care compliance. This includes all
facets of compliance (e.g., billing, research,
human resources, all Office of Inspector
General focuses, Recovery Audit Contractors,
etc). The full list could take up the remainder
of this page. The role of the compliance officer
and the Compliance department within
the acute care facility is vastly different from
that of the information that is received by
physicians, physician group practices, and
private physician practices.
Fortunately, larger physician group practices
have ties to the medical centers with which
they have relationships. This typically allows
these groups to receive formal compliance
training, and hopefully, the appropriate
required education as well. Unfortunately,
more often than not, physicians only receive
the basics of compliance during their
orientation period, or during a mandatory
annual Compliance session that frequently
only covers the highlights of the aspects of a
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well-functioning compliance program. Very
rarely do these educational sessions go into
great detail about how easy it could be for
one of them to commit a simple act of fraud
or abuse.
Independent physician practices with no
“formal” ties to hospitals/health centers are
a population at greatest risk for exposure of
violating compliance rules and regulations.
There are several reasons why this is the case,
many of which could be easily avoided. The
primary reason is lack of communication.
Physician practices, as with most clinicians,
have a primary goal to provide outstanding
patient care. This is the primary concern of
the clinician, as well it should be. In today’s
age of scorecards, dashboards, and physician
measures, there is a competitiveness that
exists, not just between hospitals to provide
excellent care, but for physicians as well. All
of this information is readily available on the
Internet at the click of the mouse, if a patient
decides to conduct research on Dr. Jones
before his/her visit.
As we visualize an independent physician
practice, there is typically some form of
office manager, there may be nursing staff
or medical assistants, possibly phlebotomy
staff, and then physicians. After treatment of
the patient is completed, the next priority in
these smaller offices is collecting money. This
is accomplished by getting claims out the
door as quickly as possible. Unfortunately,
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
documentation may not always support the
medical necessity for the visit level being
billed, or there may be unbundling of procedures
being performed within the setting.
These staff are not trained compliance professionals
and often do not have the knowledge
to know where to search. Subscribing to
periodicals or joining organizations such as
HCCA will allow the office staff to remain
up to date with new rules and regulations as
they are disseminated from the regulatory
authorities. Failure to do so can be interpreted
as fraud and/or abuse. Unfortunately for the
physician, “I didn’t know better” is not a valid
reason for billing for services that were not
performed or appropriately documented.
A savvy office manager can make excellent
use of the office budget by joining HCCA
or other similar, non-medical professional
organizations. I have seen, over the years,
that only a handful of medical professional
organizations/societies do a commendable
job of keeping their membership updated
with rules and regulations as they pertain
to billing, compliance, fraud, and abuse.
By establishing that connection with a
group such as HCCA, Healthcare Financial
Management Association (HFMA), American
Association of Healthcare Administrative
Management (AAHAM), or Medical Group
Management Association (MGMA), the connection
is made, and the individual running
the operations of the office is now tapped into
a wealth of information that might not be
otherwise available to the clerical and clinical
staff. The decision would then need to be
made regarding how and when this information
is distributed to the physicians within
the practice. Even a confident office manager
who subscribes to ten publications and is a
member of five organizations is only as good
as the information that is disseminated to the
clinicians within the practice.