Office compliance 101: A guide

In the midst of taking care of patients every day, doctors across Massachusetts are struggling to comply with an overwhelming number of constantly changing state and federal regulations.

Related story:

Can you do it yourself?

Medical professionals “don’t have the time to think, let alone deal with the 30 different [regulations] on the state and federal level,” said Michael Manere, vice president of sales at Total Compliance Solutions in Wellesley.

Physicians must follow federal regulations under the Health Insurance Portability and Accountability Act, known as HIPAA; The Occupational Safety and Health Administration, or OSHA; The Centers for Disease Control, known as the CDC; and Medicare and Medicaid, among others.

There are also a host of other federal and state regulations covering:

• Billing and coding;

• Recordkeeping;

• Insurance fraud;

• Patient boundary violations;

• Informed consent;

• Licenses to practice medicine; and

• Delegation of care.

While HIPAA and other privacy concerns are of paramount importance, experts said many physician offices don’t focus enough on the many other high-risk regulatory areas, especially those that affect billing.

The sure-fire way to stay out of hot water is to overcome the fear of regulatory compliance and dedicate yourself and your staff to following the rules. That means you must learn the regulations, follow them and train your staff to do so as well.

While relatively expensive, third-party companies can provide compliance plans, but if a small office can dedicate roughly 15 hours each month of one employee’s time, it’s possible to do it in-house. (See “Can you do it yourself?” on page 18.)

Documentation and coding

Compliance experts agree that the biggest risk area is coding and billing for Medicare, Medicaid and insurance reimbursements.

Sometimes physicians don’t comply with these rules because the codes for procedures are confusing and time-consuming to figure out and document. Some physicians have a tendency to under-bill when they aren’t certain about their documentation of a more expensive procedure.

A physician might say, “‘I’m just going to under-code; then I don’t have to worry about whether I’ve documented it correctly or not. I’ll just bill the lower code,’” explained Tray Dunaway, a surgeon and compliance guru based in South Carolina.

The problem with under-billing – which is also considered fraud because you’re billing for a service you didn’t perform – is the physician isn’t reimbursed at the proper level for the services provided.

Another problem, Dunaway said, is that physicians sometimes resent surveillance.

They might think, “‘Why should I have to prove I did anything? Can’t you just take my word for it?’ For the vast majority of physicians you can, but there are people out there who have abused that,” said Dunaway, who has developed a coding system for physicians.

However, he maintains that it’s easier to be in compliance than out of compliance, and that once physicians understand the rules precisely, coding correctly can take less time than coding incorrectly. Plus, chances are the right code is a higher-paying one.

Physicians can hire a third party to develop a plan for billing and coding tailored to their practice and to train their staff on how to use it.

“A training session shows the staff the doctor cares and recognizes there might be a problem and lets the world know they’re fixing the problem. That transparency is good,” said Vincent DiCianni, owner of Affiliated Monitors in Boston, a company that specializes in compliance programs. “It helps boost morale and also increases people’s awareness.”

Delegating care

Delegating care to various health care workers is another area where offices get into trouble because they aren’t following the regulations related to what functions a nurse practitioner or physician’s assistant are allowed to perform.

First and foremost, physicians must ensure that all members of their staff are credentialed and allowed to provide care in Massachusetts. They must also perform background checks on all staff members, compliance experts said.

It’s important to know if a caregiver was under supervision in another state or asked to leave a practice because their records were bad or their judgment was at issue,
DiCianni noted.

Then, physician offices must be sure they know the scope of services each caregiver is allowed to provide.

“Oftentimes the nurse practitioner or physician’s assistant is providing services he is not credentialed to provide,” said Lyn Henderson, vice president of medical staff and regulatory affairs at the Needham campus of Beth Israel Deaconess Hospital and a private compliance consultant. “A lot of times these people aren’t credentialed for the insurance company, so you’re billing incorrectly because you didn’t realize they needed to sign up.”

Patient follow-up

Other problems arise with tracking patient care.

HMOs and Medicare are often concerned about whether high-risk or sick patients are receiving follow-up care and tests, and that they are receiving this follow-up in a timely manner, said Anne Huben-Kearney, a clinical manager in the risk management department at ProMutual Group in Boston.

If physicians sign off on a patient’s diagnostic or lab work without looking at it carefully, or if the staff automatically files those results without showing them to the physician, the physician may never know of an abnormal result that requires follow-up.

Huben-Kearney suggests that offices have a policy that no test results are filed unless the physician has dated them and signed off on them.

Documentation of telephone calls with patients is also becoming a bigger problem. Offices need to set up systems for delivering messages to a physician when a patient calls to ensure that calls are returned in a timely manner.

Members of a physician’s office staff need to know the “magic words” that signify serious illnesses, such as chest pain, the worst headache a patient has ever had and other phrases that signal a life-threatening situation where the physician must be notified immediately.

“The second part is documenting those calls,” Huben-Kearney said. “It’s a good practice to have telephone pads, but the best practice is to make sure it’s in the chart.”

Companies like ProMutual help doctors develop and implement more detailed procedures to follow up with their at-risk patients, she said.

Other concerns

Other compliance issues to pay attention to include:

• Legibility of the record.

“It has to be something that everybody can read. Handwriting, abbreviated symbols and the hieroglyphics we all use [aren’t sufficient.] Make sure you’re documenting appropriately and legibly, and make it a permanent part of the record,” Huben-Kearney said.

Records travel with the patient and they’re useless if they can’t be read by the next physician.

• Informed consent.

“[N]ot being able to present informed consent – that a patient was fully aware and making a rational, personal decision to consent to a particular procedure” – can get offices into trouble, DiCianni said.

When physicians give an “English form to a Spanish-speaking person, are you really getting informed consent? That can be crucial, particularly with surgeons and practices dealing with certain kinds of treatments.”

• Boundary violations.

“Improper touching or not explaining you’re going to be touching or when a doctor starts revealing his or her personal life, that crosses a line of professional conduct,” DiCianni said.

While it’s rare for a physician to be sent to jail for noncompliance, there are financial and reputation-related consequences.

“Medicare not only wants the money back for the incorrect billing, but they can [calculate] that you’ve been doing this for, say, the last seven years and they can fine you back,” Henderson said. One of her clients once faced a fine of $1 million calculated this way.

Another typical consequence is the loss or suspension of a physician’s license to practice. That can happen even if the regulatory violation is a staff person’s fault. The fact that staff members practice under the physician’s license underscores the importance of properly training them.

Physicians also want to avoid negative attention in the press related to noncompliance.

“I tell my clients not to worry about the fine,” Manere said. “It’s your name in the paper, and the litigation that’s going to follow if you didn’t follow federal or state law.”

Questions or comments should be directed to the
editor at: reni.gertner@mamedicallaw.com