Adopt these ‘best practice’ methods to deter a Medicare audit

Complacency often affects both large and small practices, regardless of how productive or successful they may be.

Issue: February 1, 2000

Does your practice’s Medicare billing and coding process suffer from complacency? It is a common malaise that affects both large and small practices, no matter how productive and successful they may be. Oftentimes, the prime trigger for this ennui is lax monitoring and communication.

Here are some ways that ophthalmologists can put a much-needed “spark” into their billing and coding practices. By following these suggestions, you may improve office productivity and morale, and perhaps avoid that much-dreaded encounter with the Inspector General:

Keep a neat paper trail; ensure that patient files are complete. Granted, it takes foresight and additional labor to ensure that patient records and lab results are filed together. However, in Medicare parlance, patients’ charts are source documents for all information. Should an audit be conducted on your practice, and critical patient information cannot be found within those records, the Medicare auditor has the right to refuse to look anywhere else in the office for it. Do not forget to include documentation on telephone calls between staff and patients.

Treat every Medicare patient with respect. Medicare’s effort to incentivize beneficiaries for turning in their physicians for possible fraudulent billing practices certainly puts ophthalmology practices in a delicate position. Should patients be unable to interpret their explanation of benefit statements (explanation of benefits [EOBs]) or question certain line items, Medicare has placed a bounty over their physicians’ heads to report possible wrongdoing. Consequently, it is incumbent upon every practice to be meticulous and proactive in communicating with their Medicare patients. No matter how busy practices are, ophthalmologists must ensure that every senior is fully briefed on how their exams, tests and procedures will appear on their EOBs, which includes taking the time to answer patient questions using layperson’s terms.

Be accurate in reporting. As a practice management adviser, I have witnessed numerous practices take the “easy way out” in coding patient claims the way they believe Medicare and their carrier want to see them. I also have seen this approach backfire when practices are hit with an audit, and claims and chart documentation do not fully jibe. The moral of the story is to make sure claim coding is in sync with patient records, even if it means spending a little more time researching and backing up your documentation. Also, make sure that everything you bill for is documented.

Protect your provider identification number (PIN). Another practice that may come back to haunt ophthalmologists is allowing others to use their Medicare PIN. That includes technical services performed by employees who work for them, non-physicians who work under their supervision and services performed in a hospital by residents. If you perform an exam or a service, you must document and sign the chart.

Keep track of patients’ progress and needs. If you have not seen a Medicare patient in more than 6 months, do not sign orders, prescriptions or certificates of medical necessity without a follow-up visit. It is not only required by Medicare, but also it is good practice. To foster strong patient relations, I encourage physicians and staff to explain this government ruling to patients requesting these services. That way, patients understand that their providers are working honestly and ethically on their behalf to satisfy Medicare’s requirements.

Make sure hospital, nursing home visits appear on charts. At some point, ophthalmologists have to make calls on patients who are physically unable to visit them. It is key for ophthalmologists to document those activities on patients’ charts, and file that information in the ophthalmology practice. Also make sure patients’ names appear on every page, and that pages are securely fastened in the charts.

Be ethical about your use and billing of outside services. Medicare has no mercy on physicians who abuse the system, especially when it involves proprietary interests. For example, do not order large numbers of ancillary tests to be performed by entities or individuals with whom you have a financial interest, rent space or otherwise pay you based in part on referrals, and then bill Medicare. A simple rule-of-thumb is this: if it was not documented, do not bill.

Be a vigilant boss. No matter how well tuned a practice’s billing procedures are, the ophthalmologist needs to be involved in all billing functions. If the practice uses an outside service, the physician must insist on periodic reports and meetings with the firm. When setting up working arrangements, ophthalmologists should avoid contracts arranged on a percentage basis, as they may encourage sloppy output. Remember, as the reporting ophthalmologist, you are ultimately responsible for how others provide services on your behalf. Monthly reports and periodic meetings are good ways for physicians to stay attuned to activities performed by staff and contracted help.

Be nosy in the office. Of course, most ophthalmologists’ proclivity is medicine, not office administration and the ensuing dynamics. However, ophthalmologists must stay in touch with staff to ensure that all employees follow “best practice” procedures and standards in everything they do. No matter how tempting it is to let someone else perform office tasks, ophthalmologists need to be involved. They need to participate in staff meetings, require that all employees answer to someone else and crosscheck each other’s work, conduct spot chart reviews and EOBs, and make sure that the practice’s compliance programs are current and being followed.

Insist on a well-tuned compliance program. No matter how small your practice is, someone — I suggest a supervisor or manager — should be in charge of running your practice compliance program. This individual needs to stay abreast of current Medicare regulations. He or she must ensure that the practice operates within those standards, train new hires and retrain existing staff periodically. Depending upon the individual and his or her workload outside of compliance, this person also may be in charge of reading and distributing compliance updates from Medicare and carriers, and serving as the practice’s Medicare patients’ liaison. Also remember: consistency in billing and coding is absolutely essential. This may be especially challenging when ophthalmologists run multiple offices, so I strongly advocate the adoption of a common program under one manager.

Vigilance pays off

By adopting a hands-on, “communicative” approach with billing and coding procedures, ophthalmologists can keep staff motivated, diligent and can achieve the positive and consistent results they require. If you need a “boost” to get enthused about billing, I strongly advise you to consider the use of outside consultants. These experts can evaluate existing procedures and staffing, bring important issues to the forefront for you, and help you get and stay in charge.

For Your Information:

David Steinberger is a reimbursement specialist with Eyecare Consultants Ltd., providing consulting and networking services to ophthalmologists and optometrists. The company is headquartered at 270 Amity Road, Ste. 220, Woodbridge, CT 06525. To receive information on Medicare billing and coding advisory services, call (800) 633-6962; fax: (203) 389-4660; e-mail: neecare@aol.com