Compliance + Compliance = More Compliance?

  If compliance regulations, rules, and policies are so effective, why does it seem as though the more we have, the more we need? After all, isn’t the idea that if we regulate, supervise, and mandate … that things should get more in control instead of out of control?

  There are at least 18 organizations and agencies related to the practice of hyperbaric oxygen therapy (HBOT). As this author began to compile all of the different compliance issues that are important to understand when managing a hospital-based hyperbaric clinic, or really any healthcare facility for that matter, it became quite clear that our once revered industry has lost much of its original integrity. Think about it, the only reason anyone needs rules and laws to begin with, is because we have a desire to break them. I don’t need a law to tell me not to kill my dog, because I have no desire to kill my dog.

  We are all very quick to criticize the government, other regulatory agencies, and even our own administrative teams when we are told we have to make another change in our system of care in order to remain compliant. Granted, a lot of the burden seems to stem from the fact that there is little coordination between the regulatory organizations, but again, many of the rules only get made because it is a given that some will spend more time and energy into figuring out how to get around compliance instead of just doing the right thing, before being told to do so.

  Certainly it is necessary to have regulatory initiatives in healthcare in order to monitor progress and identify weaknesses. By the very nature of the healthcare industry, compliance measures are an integral piece of any service offered. Our services connect with human beings on a very personal level and because all of us are affected by the lack of scruples of a few, it is necessary to be proactive.

  A good compliance program will address both external and internal issues. Managers should have a thorough understanding of national, state, and local operational, documentation and billing guidelines, as well as ways to monitor patient compliance.

  Hyperbaric medicine has certainly had its share of fraudulent activity primarily surrounding billing and documentation incidents. For example, documentation that did not support medical necessity for the diagnosis submitted or billing for physician supervision fees when attendance requirements were not being met. Because CMS is required to pay a claim within 30-days of submission, it is virtually impossible for them to review each and every claim for medical necessity. Therefore unless the claim fails to pass the coding edits and is submitted clean, more than likely it will be paid. But should it have been?

  Currently the Centers for Medicare & Medicaid Services (CMS) are taking some aggressive steps in an attempt to maintain the integrity of our industry providers and suppliers with some of the newer programs implemented. One most recently launched is the national recovery audit contractor (RAC) program (https://www.cms.hhs.gov/rac).

  These program integrity contractors will look at provider billing trends and patterns and are paid on contingency fees based on both overpayments and underpayments that they find. They will focus on companies and individuals whose billings for Medicare services are higher than the majority of providers and suppliers in the community. The RAC demonstration program resulted in over $900 million in improper Medicare payments that were returned to the Medicare Trust Funds between 2005 and 2008, and nearly $38 million in underpayments returned to healthcare providers. With the success of the pilot program, congress has decided to make the program permanent and expand it through out the country.

  This aggressive effort made by Medicare to find and prevent fraud and abuse, calls all clinicians to step-up their own efforts to ensure accurate documentation is being done. As well as managers to diligently review departmental process and educate physicians and staff on documentation/billing guidelines. To avoid potential pay-back scenarios:
     • Establish self audits that are implemented quarterly
     • Know your Local Coverage Decision (LCD) policy documentation guidelines
     •Establish strong communication/educational relationship with facility coding specialist
     •Review and update chargemaster quarterly
     • Include staff and physicians in quality assurance education and participation
     • Ensure documentation supports primary diagnosis code

  These days a clinic manager has to have a solid understanding of what can be some very complex compliance issues. It is in their best interest to make every effort to understand regulatory issues that encompass the broad spectrum of their specific service line.

  In conclusion: Compliance rules and regulations have forced all healthcare providers to take our process of care as seriously as our standard-of-care. Just as the Ten Commandments were given to protect the Israelites from their own longing for the mud, adhering to compliance initiatives should be viewed as a means to keeping us free to take care of patients and protect the integrity of our industry. The more that a manager involves the physicians and staff on all levels of the compliance program the more likely less time and effort will be spent on trying to get around them or worse yet, suffering the consequences of ignoring them.

Toni Turner, RCP, CWS, FCCWS, is President of Protia Health Initiatives, LLC, Wound Care & Hyperbaric Medicine Consulting and a member of the Catholic Medical Association. She can be reached at toni@protiahealth.com.

References

1. Workman – Regulatory Compliance.ppt (2007)