MPM Publications
Part 2: OIG Guidelines Require Provider Action
Editor's Note. This is the second in our series on the OIG guidelines for billing companies. In this article, we continue with the integration of compliance goals of your physician group and your billing company.
As you review your billing company's written policies and procedures, be sure they address the following:
- Proper and timely documentation is obtained before billing;
- Claims are submitted only when proper documentation is obtained;
- Diagnosis and procedure codes are based on the medical record;
- Compensation to coders and consultants do not provide financial incentive to improperly code claims;
- A process for pre- and post-submission review of claims exists; and,
- Billing personnel obtain clarification from providers on confusing or inadequate information. How often does your billing company ask you for clarification?
Your billing company should maintain a complete audit trail of all credit balances and ensure credit balances are identified and resolved in a timely manner. The billing company should refer to state escheat laws for specific requirements relating to notifications, time periods and payment of unclaimed funds.
In its written policies, your billing company should address technology issues that include procedures regarding routine data back-up, documentation of audit trails, measures to prevent data contamination by outside parties as well as unauthorized access and disclosure, perform regularly scheduled virus checks, and Y2K issues. Also, a billing company's compliance plan should discuss its records system-the creation, distribution, retention, storage, retrieval and destruction of documents.
The compliance officer manages the compliance program and should have full authority to stop the processing of claims that he/she believes are erroneous until the issues are resolved. Make sure you are notified in advance and in writing whenever this occurs. Not only for awareness but for cash flow purposes as well.
The compliance officer also supervises and coordinates the compliance program's education and training. You may be asked to attend initial and annual sessions of your billing company's training programs. Ask your billing company to supply your practice with its requirements for continuing education of coding personnel. Billing company employees should earn a minimum number of educational hours each year and courses should be taught by a professional. This will assure you that appropriately trained personnel are handling your claims.
Does your billing company regularly publish a newsletter? The OIG encourages this type of communication because it consistently presents the message of compliance. Newsletters should be distributed to billing company employees, providers, vendors and consultants.
If your billing company is small, it may not have the resources available to establish a compliance hotline. However, alternative methods of reporting paths should be utilized; e-mails and written memos or letters are acceptable. If a hotline is available, the telephone number should be readily available to the billing company employees and highly publicized to independent contractors, providers and consultants. In addition to a company hotline number, the Health and Human Services-OIG hotline number should be included on reference material. That number is 1-800-447-8477 (HHS-TIPS).
Violations and investigations may occur even though a billing company has developed a compliance plan. If a violation is detected, the compliance officer should take steps to correct the problem. Such steps may include immediate referral to criminal and/or civil authorities within 60 days of the violation, a corrective action plan, a report to the government, and notification to the provider of any overpayments, if applicable. The self-disclosure protocol is listed on the OIG's website:
www.dhhs.gov.
If the billing company finds evidence of misconduct on the provider's part, all questionable claims should not be submitted and the provider notified, in writing, within 30 days of such a determination. Should the billing company identify continued misconduct on the provider's part, they may terminate your service agreement immediately and report the misconduct, with all evidence attached, to the appropriate authorities within 60 days of the violation. Reviewing and participating in your billing company's compliance plan is an investment in time and energy. However, it is a good business decision and one that may significantly reduce risk to you and your medical practice.
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