Physicians should take hands-on, proactive approach to compliance, attorney says

Practices need to adopt compliance plans, disclose financial relationships and learn about new Medicare rules.

Alan E. Reider

Physicians need to step up compliance efforts to weather robust regulatory enforcement initiatives related to federal health care reform legislation, an attorney said.

“I have never been busier, I am sad to say, where I have been working defending physicians, hospitals and health care entities against alleged fraud. It’s absolutely over the top right now,” Alan E. Reider, JD, MPH, OSN Regulatory/Legislative Section Editor, said at OSN New York 2011.

Mr. Reider urged physicians to take an active role in developing and implementing compliance plans to prepare for provisions of the Affordable Care Act scheduled to take effect in the next few years.

He advised physicians to review their financial relationships with pharmaceutical and device companies. Beginning sometime in 2012 and depending on the issuance of final regulations, payments made by pharmaceutical and device companies to physicians will be reported to the secretary of the Department of Health and Human Services and posted on a government website in 2013, Mr. Reider said.

“The bottom line is that there is nothing wrong with being a consultant. In fact, that’s the way that medical technology and innovation progress. We desperately need physicians to participate. But you have to be prepared,” Mr. Reider said.

Compliance, billing

Mr. Reider advised physicians to implement compliance plans now, even before some regulations take effect.

“You don’t get any brownie points for doing what you have to do,” he said. “You may get some consideration if you take the initiative and do it before it’s mandated. … Don’t wait.”

A compliance plan requires open communication and getting all employees of a practice onto the same page, Mr. Reider said.

“You have to create a culture within your practice to make sure that everybody knows it’s their responsibility to comply and to advise you if there’s a problem. You can’t have fear in your practice,” he said. “If the physicians don’t take compliance seriously, nobody in the practice is going to take it seriously. My message here is: Put in place a compliance plan and do it right.”

Every compliance plan should include an annual billing and coding review, Mr. Reider said.

“Certainly, if you have somebody come out and they tell you that you’re billing something incorrectly and you ignore it, you’re creating a bigger problem,” he said. “So, obviously, follow the recommendations. Be prepared.”

Physicians should seek advice from professionals who specialize in such services, not from fellow physicians or drug or device companies.

“If you’re going to get advice, get it from the right people,” Mr. Reider said.

In addition, Mr. Reider recommended that physicians purchase fines and penalties coverage to protect them in the event that they are the subject of a civil False Claims Act settlement or other enforcement action.

Medicare, ACOs

Physicians may bill Medicare patients for non-covered services but not necessarily for services for which Medicare does not reimburse, Mr. Reider said.

“That’s a very fine distinction but it’s a very important one,” he said. “If you have questions, go ask your carriers. There’s a lot of struggling going on right now on this topic and, again, you need to be sensitive to it.”

Accountable care organizations (ACOs), private entities designed to increase efficiency and cut costs in Medicare and Medicaid, commenced operations on Jan. 1.

“These entities will continue to operate even if health care reform is repealed,” Mr. Reider said.

As ACOs prepare to activate, many private insurers are developing similar health care delivery templates, Mr. Reider said.

“The private side has said, ‘This makes sense. We want to change the paradigm. We want to change the way health care is delivered. We’re going to empower physicians to make decisions about how it’s being delivered and we’re going to reward them as long as the care is right and if we can save money,’” he said.

Mr. Reider disputed the belief that specialists will not be affected by ACOs. He advised specialists to educate themselves and seek information from professional societies. – by Matt Hasson

• Alan E. Reider, JD, MPH, can be reached at Arnold & Porter LLP, 555 12th St. NW, Washington, DC 20004-1206; 202-942-6496; email: alan.reider@aporter.com.
• Disclosure: Mr. Reider is a partner with the law firm Arnold & Porter LLP.