Don’t fall prey to the myth that only larger practices are on the regulators’ ‘radar.’ “To tell you the truth, most of the practices I’ve been working with and I’ve been helping are small practices — one doctor practices that have been either investigated, indicted, and had problems with authorities,” says billing expert and frequent AudioEducator speaker Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO.
“Sorry, it’s not the 1980s, and you’re not going to get paid for being a ‘highly valued specialist,’” Cobuzzi has said. She cites one Manhattan specialist who refused to bill any codes below 99214 because he felt like he deserved it, rather than going by what his documentation supported. All doctors must support their claims with documentation, no matter how specialized they are.
If you hang around compliance experts, you’ll hear something like this phrase so often that it can seem like a cliché. But there’s a reason they make this point over and over again. All too often, physician practices and other healthcare organizations believe they’ve “taken care” of compliance as long as they have written policies on file. Some practices go so far as to purchase pre-written plans, fill in their practice information on the front page, and file it away, never to think about it again.
Beware: A binder on file is not enough to protect you if an audit ever occurs. Compliance is a multistep process that does not stop after you file away your compliance plan. A pre-written compliance plan may be a good place to start, but unfortunately, it provides a false sense of security for several reasons. First and foremost, a compliance plan needs to be directed at the various regulatory, payment, operational, and legal issues that are most implicated for your specific practice.
Remember: CMS policy states that each practice or organization should look carefully at areas of exposure to make sure that it has adequate systems in place to monitor and correct sources for potential claims and penalties. If you simply buy a compliance plan off the shelf, it is less likely to be integrated into the operations of the practice. Instead, create a customized compliance plan after determining your biggest risk areas and include details that are tailored to the issues you face.
To develop a culture of compliance, practice managers must master compliance literacy for themselves and all of their employees. This broad understanding helps everyone use good common sense when they make decisions at work that may impact compliance. This book is designed to help you, your clinicians, and your staff build your compliance literacy.
What this book won’t give you is instant compliance expertise. We simply equip you with enough literacy to know when you need to bring in outside expertise training, audits, risk analysis, or legal review. Throughout the book, we’ll help you discern between compliance tasks you can do well in house and compliance tasks that may require reinforcements.
The old joke, of course, is that the government is never here to help. When it comes to compliance, however, such a pessimistic attitude may be a tad unfair. Compared to the early days of the government emphasizing healthcare compliance back in the late 1990s, our regulators today can be very helpful. Some guidance from the government has been much clearer in recent years than in the 1990s. Some websites are actually helpful now — though the CMS website remains a Byzantine conundrum.
While no one wants regulators to come knocking at your door, various agencies release guidance and publications to help physician practices build and maintain compliance programs. The HHS OIG, for instance, publishes its Work Plan annually and semi-annually, and that can be a great tool for practices seeking to target their risk areas. Throughout this book, we refer you directly to government publications, audit reports, and other materials that can help your practice stay out of trouble. Don’t go paying for compliance training materials until you learn what’s available from the government for free.
There are so many of these materials available that some practices wrongly assume that no federal regulator will hold them accountable for knowing them all. “Nope,” Cobuzzi says. “If a rule is out there, you need to follow it.”
Remember: “It’s just like from a speeding perspective: If you’re on a road with a 50 mph speed limit and a sign drops the speed limit to 30 mph and you didn’t see it and you’re still going 50 mph and the police stop you, they can give you a ticket for going 30 mph in a 50 mph zone … it doesn’t matter if you saw it, it was there, it was your obligation to be aware of the signs,” Cobuzzi explains. “It’s the same thing with Medicare, Medicaid, and the private payers because they then use the system to go after you if you don’t follow their rules.”
Responsibility for compliance risk and mitigation begins and ends with you. Get the guidance you need. Pick up your copy of the Physician Practice Compliance Sourcebook today.