Compliance: Cost or Investment?

As they navigate payer re­­quirements, practices and care facilities find that they are able to reach their highest standard of documentation and billing compliance only by applying fo­cused effort and dedicated resources. Although the importance of efficient, accurate processes seems obvious, it is often overlooked or minimized in light of the resources it takes to implement them (money, staff, and the ability to manage often unpopular policies) and achieve what should be the highest standard of care in today’s healthcare environment.

Over the past decade or so, quality and efficiency have been well-publicized goals of our healthcare system. This is evidenced by the numerous programs developed and put forth to providers, including but not limited to the Physician Quality Reporting System as well as incentives for implementing electronic medical records and attesting to the meaningful use of these systems.

To further examine these goals, the Centers for Medicare & Medicaid Services (CMS) released a paper in November 2013 titled “CMS Quality Strategy 2013–Beyond.”1 Developed in accordance with legislation in the Patient Protection and Affordable Care Act of 2010, the paper outlines clearly defined goals as well as strategies to attain them.

“CMS, is working to support the delivery of consistent high-quality care, promote efficient outcomes in our healthcare system, and ensure that health insurance remains affordable for the millions of Americans who seek coverage,” the report states.

Along with CMS goals and initiatives for quality, numerous programs, task forces, and agencies have been developed to ensure that payments received are warranted and supported within a patient’s medical record. In February 2014, Attorney General Eric Holder and US Department of Health & Human Services Secretary Kathleen Sebelius released the annual Health Care Fraud and Abuse Control (HCFAC) Program report.2 It showed that for every dollar spent on healthcare-related fraud and abuse investigations through this and other programs in the past 3 years, the government has recovered $8.10.

This represented the highest return on investment in the 17-year history of the HCFAC Program. With these results, it is safe to assume that these programs will continue to seek and recoup inappropriately paid monies by conducting extensive medical record reviews and close oversight of healthcare providers.

“The Program’s continued success confirms the soundness of a collaborative approach to identify and prosecute the most egregious instances of health care fraud, to prevent future fraud and abuse, and to protect program beneficiaries,” the report states.

So, what is the cost of compliance for your facility or practice? How is your return on investment quantified for implementing a strong compliance program? Ac­-cording to the Patient Protection and Affordable Care Act, providers who treat Medicare and Medicaid beneficiaries are required to establish a compliance program. On its website, the Office of the Inspector General (OIG) provides a blueprint for the requirements of a successful compliance plan. These include medical record reviews and a well-publicized action plan on ways deficiencies will be addressed. Program guidance documents for various segments of the healthcare industry can be located on the OIG website.3

To focus on one component of the overall goal of compliance, facilities and providers can implement a streamlined process of thoroughly reviewing all medical record documentation and accurate charge capture before submitting claims to payers. By implementing a comprehensive review in which every service captured for billing is assessed to compare documentation to the charge capture, a provider may alleviate inappropriate billing practices. This process will not only identify inappropriate billing for undocumented services, but may also reveal procedures billed at incorrect levels, items or procedures that were performed and not billed, and, finally, provide a means for continuous education of physicians and staff regarding compliant documentation and billing habits.

As a provider, you have options when considering the cost of this vital review process. Perhaps a current staff member can be designated to manage it. You may hire a person dedicated to performing these duties, or the review may be outsourced to a qualified entity. Be sure to avoid a cavalier attitude that discounts the potential issues your facility or practice may have. At the very least, an in-depth evaluation will help assess your level of current documentation and billing compliance, and identify what you need. While focusing on the incentives put forth by payers, getting the basics right can ensure that the monies you receive are justified and are not at risk for recoupment.

Beyond documentation and billing compliance, it is essential to focus on your entire revenue cycle to ensure financial health. Making sure each phase of the entire revenue cycle is conducted properly will pay off in terms of revenue and compliance. Too many facilities concentrate solely on one component of the revenue cycle, such as the documentation and coding aspect. You must go beyond and investigate the effectiveness of the interfaces that move charges from one software system to another. In addition, the coding scrubber systems being utilized, whether they are software driven or manual, should be tested.

Lastly, the information that is going to the payer must be scoured for correctness. Compliance doesn’t end in the clinical department, but should be verified throughout the revenue cycle process. While implementation and review of so many processes and systems may sound daunting and costly, you will find that investments to ensure compliance are worth making. l

1. Centers for Medicare & Medicaid Services. CMS Quality Strategy 2013 – Beyond. Published November 18, 2013. Accessed April 30, 2014.
2. US Department of Health & Human Services, US Department of Justice. Health Care Fraud and Abuse Control Program: Annual Report for Fiscal Year 2013. Published February 2014. Accessed April 30, 2014.
3. US Department of Health & Human Services, Office of the Inspector General. Compliance Guidance. Accessed May 1, 2014.

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