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OIG encourages Medicare providers to institute compliance programs
A medical records consultant provides tips on conducting internal audits.
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The Office of the Inspector General acts as the “enforcer” for the Centers for Medicare and Medicaid Services. This office establishes requirements for Medicare providers and creates a plan each year to guide compliance efforts throughout the system. Contractors are kept busy, conducting reviews and audits of provider billing practices as well as reviews of patient records where appropriate.
As is true with most requirements, Medicare would prefer that all providers were always compliant with its rules; if they were, audits, fines and penalties would not be necessary. Based on Medicare’s long history, however, it is pretty clear that voluntary compliance has not been enough. In spite of Medicare’s best efforts, including the Office of Inspector General’s (OIG’s) annual warnings, many providers seem to be ignorant or unaware of the requirements of their Medicare contract and/or unaware of methods for ensuring that their practices are compliant with those requirements.
OIG requirement for internal monitoring
About 15 years ago, the OIG instituted a policy that requires all hospitals and large medical clinics to establish and maintain an ongoing internal program to monitor and ensure compliance with the national standards related to medical record keeping. When audited, any such facility that is found to be without a medical records compliance program or cannot demonstrate the function of its Medical Records Compliance Program will receive warnings and/or penalties and will be expected to comply quickly to avoid further penalties.
Fortunately, most optometric practices are not considered to be large medical clinics, so the requirement does not apply. However, the OIG has encouraged all Medicare providers to institute Medical Records Compliance Programs, voluntarily, convinced that such programs are necessary and helpful to the providers and likely to result in fewer violations of Medicare contract provisions and more accurate Medicare claims.
Since first learning of the OIG’s Medical Records Compliance Program, I have been an active cheerleader for voluntary compliance. It seems logical for every office to create an ongoing program to ensure that the care its patients are receiving matches the needs of each patient, that the records generated during the provision of that care work well internally, and that codes chosen to report the care and claims generated to report the care to the payer comply with national standards and rules.
Compliance may require an extra in-office training session or two and will require assignments for staff and doctors who will be doing periodic internal friendly audits of patient charts. Most importantly, once your compliance program is up and running, doctors and staff will find themselves more confident in the charges resulting from the care that is provided and more confident that the claims submitted are accurate and, ultimately, that the practice is more likely to do well if and when the auditors appear.
In my opinion, accuracy should always be the goal, whether considering the care that is provided, the record that is kept of that care, the codes that are chosen to represent what was done or the claim that was created and submitted for payment of that care. Accuracy can never be taken for granted, of course, and a systematic effort to ensure accuracy is the only way to be appropriately confident in care, records, codes and billing.
OIG recommendations
The following are the steps that the OIG has recommended for inclusion in providers’ Medical Records Compliance Programs, along with my detailed suggestions.
Conducting internal monitoring and auditing through the performance of periodic audits. Internal chart reviews should be regularly scheduled, such as beginning with five charts per doctor each 6 months, possibly stretching to five charts per doctor per year once compliance is confirmed. Staff and doctors may need some training prior to beginning your internal audit process. The rules for proper medical record keeping and for choosing procedure and diagnosis codes are well established, accepted by all payers, and must be consistently applied to ensure proper reimbursement and good results during payer audits. The key is to have the correct and current reference materials, including the American Medical Association 2016 Current Procedural Terminology, 2016 ICD-10 and the 1987 Documentation Guidelines for the Evaluation and Management Services. The easiest and most economical way to purchase these is through the website of the American Optometric Association: aoa.org/marketplace.
Implementing practice standards through the development of written standards and procedures. By establishing your process for internal audits and making sure that you have the proper references available to all doctors and staff, you will be creating medical records standards for your practice. Essentially, the written standards may simply state that your practice is committed to complying with national standards for the provision of care, for choosing codes and for submitting claims for payment through periodic training and internal audits.
Designating a compliance officer or contact to monitor compliance efforts and enforce practice standards. This person may be a doctor or a staff person, logically one with the training, resources and experience to build and maintain your compliance program.
Conducting appropriate training and education on practice standards and procedures. Training for all doctors and all staff who are involved with patient care and billing should be scheduled periodically, possibly beginning with two sessions per year.
Responding appropriately to detected violations through the investigation of allegations and developing a corrective action program. In optometric practices the most likely violations will be related to incomplete records or incorrect choices of procedure or diagnosis codes. If such issues are discovered, the response will be additional training for the personnel involved and more frequent internal audits to correct and document necessary improvements.
Developing open lines of communication with the practice’s employees. This is always a good idea in any health care office so problems can be identified and corrected internally well before a payer audit.
Enforcing disciplinary standards through well publicized [internal] guidelines. Assuming full cooperation of all doctors and staff in the process, any enforcement will entail additional training and/or encouragement rather than any formal disciplinary actions.
In closing, I urge all doctors and key staff to fully commit to customizing all care to the needs of each patient and the needs of the doctor managing the case, to keeping excellent records of all that is done at each encounter and to complying with national rules and any contractual requirements that apply. The evidence is clear: Compliance is good for your bottom line and excellent for your peace of mind.
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- Charles B. Brownlow, OD, is a member of the Primary Care Optometry News Editorial Board and a health care consultant. For a sample outline for use in creating a medical records compliance manual, contact: drbrownlow@foresightod.com.
Disclosure: Brownlow is a health care consultant with ForeSight LLC.