Physician Compliance Program

Transcription

1 Mike Runquist Seriously? Objectives Develop Compliance Program where physician leadership helps drive the process Establish engaged physicians in your audit process Effective methods for compliance education for physicians 1

2 Physician Involvement Key to an Effective Compliance Program Committed Leadership Engenders Physician Support Physician Champions Foster Broader Participation Effective Communication Spurs Involvement Credible Auditing and Data Motivates Improvement A collaborative, cooperative compliance program with committed physician leadership fosters physician engagement and promotes early detection, prevention & correction to minimize risks of healthcare fraud and abuse. OIG Compliance Program Guidance for Individual & Small Group Physician Practices 1) Implementing written policies, procedures and standards of conduct. 2) Designating a compliance officer and compliance committee. 3) Conducting effective training and education. 4) Developing effective lines of communication. 5) Conducting internal monitoring and auditing. 6) Enforcing standards through well-publicized disciplinary guidelines. 7) Responding promptly to detected offenses and undertaking corrective action. 2

3 Getting Started Remember your goal of physician commitment to the compliance program s culture & effectiveness Include physicians in board oversight responsibility Designate a compliance committee selected from major departments and include physicians on the committee Create a physician-only subcommittee Appoint Physician Champions Perform initial and annual risk assessments Choose members of the Physician Subcommittee who are willing to become the working arm of the Compliance Committee Members should be both junior and senior physicians. They should have an interest or background in: Education & Training Audit & Monitoring Clinical Quality or other areas as identified 3

4 Major Duties of Physician-only Subcommittee Research, develop, write, present & amend policies and procedures for compliance committee Document progress of outstanding issues Investigate risk areas via quality improvement efforts Responsible for education & training (staff & physician) Responsible for auditing processes to determine effectiveness Make recommendations for enhancement Measure effectiveness Selecting your Physician Champions Ask your physician leaders for appointees or volunteers to be physician champions in key areas. Be sure to review and interview the candidates Make sure the physician champions weren t appointed as a punishment or because they needed the extra compliance training Self - Risk Assessment Each organization will have different risk areas Sets a compass for the organization to follow Identify: New policies or revisions, procedures and forms education & training opportunities audit & monitoring necessary resources 4

5 Common Risk Areas No or inadequate risk assessments Physician employment and partnership agreements Physicians & staff lack awareness Physicians not holding each other accountable for coding & documentation accuracy Disregard of physicians and employees concerns Compliance policies, procedures & documents not regularly reviewed and updated Physician business arrangements Physician Practices that implement a culture that promotes and embraces compliance are more likely to have effective compliance programs & are better able to prevent, detect & correct problems. You need more than physician champions, you need to set the tone at the top with committed physician leaders at every level. 5

6 Audit & Monitoring Program Fostering an atmosphere of continuous process improvement You want your providers to be engaged and have a sense of accountability to both the organization and to one another. The audit process must be messaged as an opportunity to identify areas in need of improvement and not as punitive. Auditing and Monitoring elements Audits and communication of results Aggregated and individual feedback Action plans and outcomes E/M utilization reports Coding intensity Distribution of codes External benchmarks Data from billing system about claim edits, rejections and denials Results of any payor or regulatory agency audits Any repayment of overpayments Auditing Effectiveness There are 4 elements for effective audit programs: 1. Standardized process 2. Communication of process steps, expectations and results 3. Quality of auditing and feedback 4. Consistent tracking 6

7 Standardization Develop an auditing manual for auditors. Manual may include the following: Standard policy Follow policy for provider E&M coding and documentation Select number of charts to review for each provider Determine acceptable accuracy percentage Determine number of failed chart audit phases prior to disciplinary action of 100% chart review and/or termination Provide report to leadership with recommendations. Guidelines Audit E&M by following 1995 OR 1997 guideline. Should we follow only Medicare guidelines? How about providers that do not see Medicare patients? Auditing process Communication Determine how you will communicate with providers: In person Telephone Teleconference Follow a standard script Determine who in leadership the audit results and communication will be shared with Quality Audit the auditor Identify auditing errors Provide additional training Develop policy on how to address job performance Audit revenue cycle Identify inaccurate coding changes Improve operational processes Provide additional training to new process Re-audit to determine if changes were effective 7

8 Tracking Track all audits in a centralized location Report back to compliance officer the results and recommendations for improvement. Regular reporting to senior leadership and compliance committee Make sure your process is consistent and transparent. If the providers don t trust the auditors, audit results, or the process, you cannot have an effective auditing and monitoring program. Monitoring E/M utilization reports Coding intensity Distribution of codes External benchmarks Data from billing system about claim edits, rejections and denials Results of any payor or regulatory agency audits Any repayment of overpayments Utilize your physician champions to identify additional risk areas 8

9 An effective tool for fostering physician accountability and engagement in your program is the use of peer review for selfaudits. Using Peer Review for Self-Audits of Medical Record Documentation You might be surprised at how much doctors can help one another improve in coding and documentation. Ronald W. Bradshaw, MD, CPA Fam Pract Manag Apr;7(4): Peer Review/Self-Audit A vital part of an effective compliance program is implementing a method to monitor your practice's coding and documentation. The peer-review self-audit process minimizes demands on physicians' time, requires no special audit training and can be completed in four one-hour sessions annually. A peer-review self-audit is not only a cost-effective way to help protect against fraud and abuse, it's also a valuable educational tool for physicians to improve their coding and documentation skills. 9

10 Benefits of a peer review self-audit: Education. Reviewing other providers' charts reinforces the essential points of good documentation. Focus. A self-audit can focus on particular issues relevant to a certain group. For example, if you are concerned about the proper documentation and coding for office visits that involve both E/M services and a procedure, you can target those visits only. Cost-effectiveness. The peer-review self-audit process requires no additional expenditures, although the opportunity cost of physician time must be taken into account. We estimate one hour per physician each quarter for participation in the actual peer-review process. Timeliness of feedback. Some of the feedback to providers is immediate (occurring during the group's discussion of the charts while the review is under way). In addition, the overall results of the review can be reported quite soon after the review is completed, particularly as the group gains experience in performing self-audits. The Process: To minimize demands on the providers' time, use the beginning of a quarterly one-hour review session to evaluate progress notes. Two progress notes (or more, time permitting) per provider should be reviewed. The providers evaluate only the progress notes from individual patient visits, not the entire chart. Providers aren't asked to review their own charts. The remainder of the session should be devoted to a group discussion of the charts and the providers' coding practices. The providers usually will challenge one another about their progress notes. Despite the potential for conflict, comments and discussion are generally well-received and tend to carry more weight when made by a peer. Follow up to the peer review self audits: Make refunds if necessary Change the focus of the audits for the next session based on issues identified or new risk areas Revise procedures if necessary Provide additional training as needed 10

11 Provider Education Accurate coding & documentation supports reimbursement & prevents violations Common Problems for physicians: under & over coding default coding ( I always code a level 3 ) lack of diagnosis specificity inappropriate use of modifiers & unbundling services deemed not medically necessary Optimal Physician Education & Training Establish a physician leader to drive education process Utilize physicians for review and/or authorship of your training material Conduct annual chart audit for each physician to establish baseline of knowledge Structure education based on those results Avoid too generalized coding sessions 11

12 Optimal Physician Education & Training Be specialty and/or location specific Standardize fee tickets & documentation templates Review in 2-3 months to determine effectiveness of training Provide your physicians with as many resources as you can Pocket Guides Smartphone/iPad Apps Concurrent coding feedback from coders/charge capture or telephone coding helpline New hire orientation Both new grads and experienced providers Sample audit within 30 days of start to assess documentation and coding knowledge Routine ongoing education All providers receive a least basic refresher at least annually Assigned training based on audit results Annual coding rule(s) updates Special situations Based on audit findings, identified issues, or regulatory focus 12

13 Benefits of physician leadership in your compliance program: Your message is heard and understood by your target audience because you ve involved physicians in crafting your messages Your training is better received when you have physician review and co-authorship You can avoid your physicians feeling compliance fatigue You help ensure the effectiveness of your program by giving physicians both authority and accountability for compliance 13