Mitigating The Risks And Factors Involved In Physician Practice Compliance

Years ago, OIG issued guidelines for physician practice compliance but in spite of that many practices have failed to imply a proactive and efficient system to implement it and stay compliant. But if this step is incorporated at a time when rules and guidelines are changing, there is immense scope of scrutiny and reducing staff, the practice will be immensely benefitted.

On the other hand, practices must keep with the present guidelines to impart high quality patient care, profit, and overcome audits. Receiving adequate training and being aware of all the developments can help to follow federal guidelines and steer clear of auditors and costly fines. This can be achieved by adhering to some basic recommendations for areas like:

• Privacy, meaningful use and security
• Clinical code and coding
• High quality data reporting

The American Recovery and Reinvestment Act are responsible to promote IT related to health.  In fact, the HITECH act has assigned huge sums of money for meaningful use of HER systems. Additionally, HITECH also has modified HIPAA to take critical care of privacy and security of patient information. Although physicians wait to benefit from the new guidelines, they need to be prepared to implement and comply with all the changes related to HIPAA or face penalties. Practices that feel that it is not important to incorporate the meaningful use program need to meet all the factors by 2014 or face severe penalties at the beginning of the year 2015. HIPAA privacy and security compliance will be under close scrutiny and practices need to be aware of it. So physicians cannot afford to take HIPAA compliance lightly. They must implement fool-proof protocols to steer clear of audits and denials.

The ultimate responsibility lies with the physician for all the actions performed by the staff members. If a charge cannot be validated by a practice, it should not be billed. With stringent compliance measures, physicians hold great liability and are under immense pressure to take up issues that will be a result of incorrect coding. In order to tackle this situation, a proactive approach is required along with correct documentation that will save time and revenue.

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E/M Auditing For Compliance: Ensure That You Are Compliant With The Documentation Guidelines

The regulatory and compliance guidelines are making their presence felt in the ever-changing environment of coding and billing so, physicians are making efforts to minimize the risk of audits. As an example, it can be said that MACs often review E/M services and any provider using targeted E/M codes are prone to audits. It is essential to keep in mind a few guidelines for E/M auditing for compliance 2014.

In order to determine the risk for an audit, it is essential to compare the use of E/M codes by the provider to other physicians. CMS publishes utilization data of Medicare Part B every year to ease comparison.

One can also review the service volume. Apart from the service type distribution that has been billed by the physician, the volume of the services offered can also lead to audits. In order to determine if the physician faces any risk, a comparison of the total annual revenue to specialty standards can be done. This information is available through MGMA and other organizations as well that are involved in gathering data and publishing reports. There are various percentiles and any provider ranking in the higher percentile group is an easy target for audits.

One also needs to analyze physicians. Usage can be separate from revenue and there is average level of service for a specialty, services need to be coded accordingly. Differences in utilization can be due to various mixes of patients, sub-specialization, increased productivity or marketed service areas. But at the same time, improper coding can be cited as a reason to high usage along with false claims and inflated documentation.

To make coding and billing compliant, it is important to understand how accurate physician coding needs to be. At the centre of every corporate compliance plan lies a truly effective auditing program. By pairing ones auditing program to highlight the auditing measures of other prominent payers one can reduce risk and ensure compliance.

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