Health Care Reform Brings Heightened Provider Scrutiny

The proposed House and Senate plans for health care reform vary considerably, but the one common element of both, give or take a few billion, is that they are very expensive. The Office of Management and Budget discusses on their website the various sources of revenue that will be used to finance this expenditure. One category they point to is the billions of dollars that are lost each year to Medicare fraud and abuse. This means that the already active revenue recovery efforts by federal and state agencies will intensify over the coming years.

Despite their best intentions, providers can find themselves facing an Office of Inspector General or State Office of Medicaid Inspector General audit, and be surprised to find out that they have been submitting claims for reimbursement that are not supported properly. It may be that the wrong procedure or E&M code was selected; or the right code was selected for what was done, but the documentation doesn't support it; or the visit was not justified medically. Nursing home providers may find that MDS completion was not based on the true condition of a resident,or that the resident experienced quality of care issues while being covered by Medicare. A home care agency may find that the ICD-9 codes they selected for prospective payment were not appropriate for the client's medical diagnoses, or a hospice provider may find that they inadvertently billed for days after a patient died because of a breakdown in communication.

While these types of events are most often not intentional, they can happen very easily from a variety of factors:

1. Staff can become so absorbed in meeting the tremendous needs of patients that they don't pay enough attention to the "paperwork".

2. Interfaces between clinical and financial information systems can have glitches that remain unknown for months.

3. Providers become accustomed to doing things a certain way for years without being told it is not a proper procedure that they assume it is proper.

4. Staff can identify an issue as not being correct, but because of workplace politics, power structures, etc., nothing happens about it, so they stop bringing it up.

So what is a provider to do to prepare for the increased scrutiny of their claim submissions? Every provider organization should have a compliance plan where the principles of revenue integrity are spelled out for all staff to see, and the expectations for how that integrity will be monitored and what a staff member should do if he or she sees something they don't think is right, is laid out. This compliance plan should include ongoing monitoring of revenue cycle processes to make certain that claims submitted are based on proper coding and are supported with the appropriate clinical documentation. Staff who show a pattern of non-compliance should be given feedback and if they do not improve, should be subject to disciplinary action. It also is valuable to have both the compliance plan, as well as a sample of claims submissions for a period of time, reviewed by an outside consultant who will be objective and provide the perspective of external scrutiny.

For more information on this topic, or to discuss how a diagnostic assessment of how effective your organization's compliance and revenue integrity processes are, contact Joseph Tomaino at 212-372-1640, or joseph.tomaino@rsmi.com .

Continuing Care InSite is the blog of Joseph Tomaino, who assists his clients with smart approaches to improving continuing care organizations. He can be reached at jtomaino@continuingcareinsite.info