OIG COMPLIANCE GUIDANCE FOR PHYSICIAN PRACTICES Washington County Hospital Association, Inc. CME Program October 26, 2000

SCOPE OF PHYSICIAN COMPLIANCE PROGRAMS Promotes adherence to and better understanding of complex rules Covers Federal health care program claims Programs are strictly VOLUNTARY Recognizes staff and resource limitations of smaller physician groups

BENEFITS OF PRACTICE COMPLIANCE PROGRAMS PATIENT CARE COMES FIRST! Patient care may be enhanced due to focus on better documentation Minimized billing mistakes can speed and optimize payment of claims Reduce chances of a HCFA/OIG audit of the practice

BENEFITS OF PRACTICE COMPLIANCE PROGRAMS “PREVENTIVE MEDICINE” FOR YOUR PRACTICE Avoid conflicts with anti-kickback and self-referral issues Sends important message to staff Shows your patients that you are making good faith efforts in billing

ERRORS VS. FRAUD?? OIG believes most physicians are honest and provide high quality care Cannot be penalized for innocent errors or even negligence Fraud is reckless or intentional conduct

AUDITING AND MONITORING MONITORING Monitor coding patterns Review practice billing procedures Review claim submission process Review a sample of chart documentation

AUDITING AND MONITORING AUDITING  Conduct detailed review of 5-10 charts per physician for Medicare and Medicaid patients from notes to claim payment  Look at coding, documentation, medical necessity and possible incentives  Creates a baseline for comparison after compliance program implementation

PRACTICE STANDARDS AND PROCEDURES Coding and Billing Reasonable and Necessary Services Documentation in the medical record and on bills Inducements, Kickbacks and self- referrals

CODING AND BILLING Claims for services not medically necessary Duplicate billing Billing for items or services not provided Billing for non- covered services as if covered Misuse of provider identification numbers Unbundling Failure to use coding modifiers Clustering Upcoding

THE “REASONABLE AND NECESSARY” DISCONNECT OIG says physicians may order any tests they believe are appropriate BUT...  Medicare only pays for services they define as “reasonable and necessary” SO TO GET PAID... Become familiar with carriers’ LMRP (Local Medical Review Policies) Issue ABNs to patients when appropriate, or you will NOT be paid

PRACTICE COMPLIANCE OFFICER OR CONTACT Need NOT add staff Can divide various responsibilities Can outsource or co- op function with other practices Final responsibility rests with the physician!

TRAINING AND EDUCATION LOTS OF OPTIONS  Seminars and classroom sessions  Newsletters  Office bulletin board  Free Internet-based courses  WCHS offerings

RESPONSE TO PROBLEMS— CORRECTIVE ACTION Investigate and correct apparent infractions promptly May require some repayment to gov’t. – don’t try to hide Remedial training may be sufficient Ask for help

COMMUNICATION An “open door” policy with practice staff is wise Bulletin board notices and “pass- around” memos are useful and inexpensive Ask for input

DISCIPLINARY ACTION Actions must have fair consequences Review proper procedures and require additional or repeat education Do keep records of personnel actions

OTHER RISK AREAS REASONABLE & NECESSARY SERVICES  LMRP  ABNs  Certifications for DME and Home Health  Billing for non- covered services PHYSICIAN RELATIONSHIPS WITH HOSPITALS EMTALA Teaching physicians Gain sharing Incentive arrangements Medical directorships

OTHER RISK AREAS BILLING PRACTICES Third party billing services Non-participating physicians Professional Courtesy MISCELLANEOUS IDENTIFIED RISK AREAS  Rental of office space to parties to whom you refer  Unlawful advertising  HIPAA regulations

GUIDANCE ALSO INCLUDES Summary of Criminal Statutes Listing of Civil and Administrative Statutes OIG-HHS Contact Information Carrier Contact Information Trailblazers Health Enterprises – Part B Internet Resources for practices

QUESTIONS OR COMMENTS? Shana Wolfe, Washington County Health System Compliance Officer Pangborn Hall, ComplianceLine

THANK YOU!