In this episode, Cyndy Kowalski, a manager in our Compliance Services Team at BESLER Consulting, discusses the relationship between physician coding and compliance.
Cyndy says that implementing a compliance program can be like proactively looking at preventive medicine. It’s something that you would want to put in place before you would actually have the need for it.
The government plays an active role in enforcing compliance through the Department of Health and Human Services, the Office of Civil Rights as it relates to patient information, the Office of the Inspector General and the Department of Justice.
The False Claims Act is where a majority of compliance issues arise. The False Claims Act sets out seven bases of liability. The most common ones related specifically to physician coding and documentation have to do with presenting or causing to be presented a false or fraudulent claim for payment or making, using or causing to be used a false record or statement to get a false claim paid.
When you think about mistakes, there are some that are purely what we would describe as administrative and documentation mistakes, such as not enough or insufficient documentation.
The services that the physician documented or the physician ordered for this patient may not have been sufficient, but that doesn’t necessarily mean that the patient didn’t need the service. The patient could have required that service, but the way that the doctor documented the order or the justification for that order was not significant enough to have that claim supported or paid.
Another area where we see some mistakes has to do with medically unnecessary services. The service based on what the patient was reporting as their concern is not supported medically by the documentation. And then there are some basic diagnosis coding errors, the wrong code was selected.
We are also seeing some criminal actions through the Department of Justice. This could be against individuals or entities in addition to civil actions. The criminal actions can result in exclusion sanctions. And basically what that means is that the provider or the entity can no longer participate in Medicare or Medicaid. When you think about the revenue that’s generated from Medicare and Medicaid beneficiaries, that’s a significant amount of money.
When an exclusion is imposed, there is no payment. And then the provider may not submit claims automatically until they are then restored.
One way to avoid being excluded is by establishing a corporate integrity agreement with the OIG.