Sound Policies Protect Against Auditing Nightmares
There is no government conspiracy … there’s not even a hidden website with all the super secret tips to avoid being penalized during an audit. In fact, when it comes to healthcare contractors and audits, the federal government is relatively straightforward regarding what they expect, how to comply and what happens if you fall short.
Scott Mertie, member-in-charge for Kraft Healthcare Consulting, LLC, noted, “As long as the providers are prepared in making sure they have appropriate documentation and provide everything the auditors are asking for, it should not be a big deal.” Of course, he added, claims need to be coded appropriately … and therein lies the rub.
Kelly Miller, a senior consultant with Kraft, said coding for the proper setting — namely inpatient vs. outpatient — is an area where providers often get dinged for improper billing. Heather Greene, Kraft coding and compliance consultant, added that another major problem for providers is they forget the very basics.
“If you did it, document it. That’s the Golden Rule of documentation. If it’s not in the chart, you can’t say it happened,” she noted. The correlating rule is that handwriting must also be legible. “If I can’t read it, it didn’t happen. That’s true in a court of law and with RAC,” she added.
While it might be staff members who are internally responsible for populating a health record, Greene reminded providers that it is ultimately the physician’s responsibility to make sure the record is complete.
The consultants agreed it’s critical to have a compliance plan in place. The Office of Inspector General (OIG) has developed a series of voluntary compliance program guidance documents by industry sector. Greene pointed out the information is prominently displayed on the OIG website (www.oig.hhs.gov/compliance/compliance-guidance/index.asp).
Although the government isn’t hiding compliance requirements or areas of focus, such as the announcement RAC auditors would turn their attention to Inpatient Rehabilitation Facilities in 2012, providers … particularly smaller groups without a dedicated compliance department … find it difficult to keep up with the sheer volume of information.
“The industry, as a whole, tries diligently to be adherent to making sure they are educated and trained appropriately, but it’s difficult,” noted Greene. “If you think about small physician offices, there’s a finite budget.”
Miller noted, “The first thing that gets your attention are the fires that come through.” For that reason, she added, reviewing compliance processes and conducting internal audits can get shifted to the back burner.
And yet, the three asserted, those activities are critical. “If you’re making mistakes innocently, it can still haunt you,” said Mertie. “The answer is you have to focus resources on making sure you are compliant.”
The first step is to put your plan in writing. However, Miller noted, “When you put it in writing, make sure you’re going to follow through with it. It’s much harder to justify why you didn’t follow the process when it’s in your own plan.”
Once in writing, it’s equally important to make sure employees understand and are trained on the processes. Mertie said there are a number of reasons healthcare companies veer from their policies including turnover rates with new employees not being properly trained, having individuals who wear lots of hats and are spread thin, and relying too heavily on technology.
Mertie added the electronic medical record is an essential component of capturing a patient’s history, and therefore documenting claims. “It’s a necessary tool in today’s age, but everybody needs to understand it still needs human interaction and monitoring.”
One example is the ease of cutting and pasting information in a follow-up appointment. “It’s called cloning,” Greene said. If that happens, however, the provider is not meeting the set standard. “That’s already been talked about for a number of years by CMS so don’t be surprised when this hits the news,” she added.
Being proactive with self-auditing and knowing your exposure is the best way to avoid or limit penalties. Whether it’s perspective provided from an internal department or an extra set of eyes hired from the outside, monitoring and auditing should reveal breakdowns in workflow.
“We’re education-based,” Greene said of Kraft’s approach. “When I see something in the chart that is a red flag, to me that offers an opportunity for education and to look at the process.”
Even when steps are corrected and the covered entity once again becomes compliant, Greene stressed the importance of reporting any mistakes found in such a review. “If you hide it, you may be facing criminal charges, as well,” she stated.
Mertie noted that taking a proactive stance might result in a company having to return overpayments or adjust claims rates in the beginning, but will ultimately pay off. “Their whole revenue cycle process improves over time.”