Some days, it appears we compliance and coding folks are like the boy who cried wolf. We see shadows around every corner. We emulate Captain Kirk, shouting, “Red Alert! Shields up!” (Done mixing my metaphors now, I promise.) The mainstream press doesn’t help with headlines of fraud accusations and sensational stories of government regulations. We read headline stories about a hospital chain encouraging physicians to admit patients who did not qualify for admission and an OIG report about investigating physicians who bill Medicare a lot of money each year. A lot of money.
How does a practice assess its real risk?
Think: big. The OIG report identified 2% of physicians responsible for more than 25% of Medicare Part B revenue. It identified 303 physicians in the country who each received more than $3 million in Part B Medicare payments in one year. These were 55% Internists, 12% Radiation Oncologists and 11% Ophthalmologists. I don’t think the Internists generated $3 million from moving their 99213s to 99214s, do you? Although the report doesn’t say what services were provided, I’m going to guess diagnostics or DME played a part. When I read about health care professionals or business types who have paid large fines or gone to jail, there is often this large component involved. The lab that bought insurance numbers and billed for thousands of lab tests on patients who were never seen. Sheer size is a risk factor. I don’t mean a group of 100 has higher risk than a group of ten. I mean, if one physician generates revenue that is 100 fold higher than might be expected, that’s a risk.
Think: different. As in, “is my billing pattern different from the norm?” That is hard to know. The government and payers have all the data: they are playing with a full deck of cards and all we have is the ace of spades and two of hearts. Check your E/M profile against the norm. (email me firstname.lastname@example.org) and look at your use of modifiers. (frankcohengroup.com) Look at MGMA RVU data to see if your total RVUs are significantly higher than the norm. Compare data internally. Avoid reporting all one level of service in any category, “all my admissions are threes, all my follow ups are twos, and all my consults are fours.” High volume combined with unusual profile is a risk factor.
Think: it’s too good to be true. That diagnostic tool the sales rep tells you will make you a fortune: take a good look at coverage rules and medical necessity.
Think: when you hire, can she whistle? When I present to a group, I often ask, “Do any of the doctors here have your spouse working in the practice? Yes? Don’t get a divorce.” But, whistleblower suits can be a threat to anyone. The hospital in the NYTimes article I mentioned is being brought my multiple whistleblowers. When you are interviewing a new staff member, be alert for an attitude that the person knew more than their previous supervisor and protected the doctor from “wearing stripes” and now plans to bring their watch dog skills to you. It’s not that I don’t want you to find and correct your own errors. That process of auditing, in which you voluntarily review your coding, correct errors, issue refunds for overpayments and educate yourself and practice is critical and should be done by every practice. But, I want the person doing it to be on your side, helping you detect errors, research the rules, refund overpayments and correct problems. I’m not saying co-conspirator! I’m saying the person who works with you in the complex area of coding and compliance should be on your team.
The only way to reduce your coding risk to zero is to stop seeing patients. But, physicians are used to managing risk in their medical decisions. Managing coding risk means learning about the codes and rules for the services you provide, hiring dedicated, smart staff and paying for coding education and conducting regular audits, internally or externally.