Yes, the risk is real.  As you work through your day to day operations, managing a never ending stream of patients, some with greater needs than others, you may wonder why compliance is such a major part of your day.  Compliance has many faces, it involves not only the quality of care that your provide to your patients, but also how you handle the myriad of government regulations.  From HIPAA, Privacy to CLIA, OSHA and billing and RAC reviews, Quality care initiatives and HIPAA Security, CHC’s are inundated with rules.

Medicare has been actively working high-producing providers who appear to be the recipient of higher than usual funds from the government.  When the government shows up on your doorstep with a subpoena, it’s after they have reviewed the available data thus a reasonable belief that the provider is a problem.  Who’s knocking at your door?  Typically Federal Agents from more than one department.  FBI, DOD, CMS may all be represented. Do your employees have a protocol to follow in the event someone comes knocking?

Why are they knocking?  It could be that someone (usually unhappy or disgruntled) from your organization told the government, usually through a whistleblower action, that your billing is less than stellar.  Or the government may just be running the numbers.  Reasons the government gave in recent cases include the extreme: “we suspect that the provider is using his Medicare practice to fund terrorist activities”, to the mundane:  your provider was excluded from billing Medicare due to criminal activity in another court (such as embezzlement), and the law is clear, that if you are convicted in another criminal issue, you cannot be a provider with CMS.

Some of the most common actions are for billing, usually because it’s easy for the government to quantify and audit.  In the larger or more serious cases, Medicare will employ a forensic accountant to review data.  But, it doesn’t mean that the people employed are experts in the field.  In one case in which I participated, the FBI asked if we wrote the 1995 and 1997 E+M Guidelines, which as just about everyone knows were a joint production by the government with the AMA!

Responding to the government in all cases is time consuming and detracts from your day to day operations. You can anticipate that if the government is going to knock on your door that the next 2-7 years are going to be spent answering to the concerns of the government and defending your positions.

Your compliance programs need to be able to address with a timely investigation and response just about any issue that is brought forward to you.  Serious infractions that put the organization at risk must be dealt with immediately and appropriately.  This means that your compliance plan cannot be templated from a kit and made to sit on the shelf.  Each year you need to review the plan as written and update it to the current climate of the industry.  Work plans for billing and other areas allow you to conduct periodic reviews of high risk areas and providers. And for any adverse findings, you will need to be able to set disciplinary measures and processes to action.

Does it really make a difference?  Absolutely, if your efforts are sincere, Medicare will see it in the data.  In one case presented by a whistleblower, the government reviewed the issue.  Numbers were run, and the government could see that changes had occurred in response to the billing problem, and as a result the billings related to the problem decreased.  The government said that because the efforts of the organization, to find and correct the issue, was apparent and successful, they would not pursue the case.

If you belong to a large healthcare system, you have probably met, worked with and been trained by the Compliance Department.  Smaller organizations may not have all the processes in place to address all issues. A yearly review of your compliance initiatives, policies and training is recommended.  Included in the review should be a close look at your billing initiatives, updates to coding and billing regulations, and training for staff.  While Compliance may seem like an added expense, the efforts by your compliance professionals may well result in major savings such as:  time saved from having to address government actions, resolving small problems before they become a major concerns, and in keeping staff trained and current, so that problems are avoided and appropriate reimbursements maintained.

Linda Howrey, EJD

Managing Director, PMG Consulting