April 2000
Volume 64 |
Number 4
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| Compliance, Billing
and the OIG: Improved Billing or Handcuffs? A Personal Perspective |
Paul J. Lipson, M.D.
Background: I have been the Compliance Director for
Anesthesia Medical Group for the past two-and-one-half years.
Anesthesia Medical Group is comprised of 70 physicians and 120
nurse anesthetists. We use the anesthesia care team model as
well as personally provided anesthetics. We have conducted up
to four mandatory seminars on billing and compliance in the
last two years. I am also the Medicare Advisory Committee representative
for the Tennessee Society of Anesthesiologists.
The following is my perspective and the lessons that I have
learned about compliance and billing over the last two years.
Update on Medical Fraud and Abuse
We began our compliance activities two-and-one-half years ago
with much fear and trepidation. We were concerned that the size
of our group would especially make us a target for Office of the
Investigator General (OIG) investigative activities. At that time,
the language coming from the Health Care Financing Administration
(HCFA) and the OIG was ominous and severe. HCFA often spoke of
"criminal wrongdoings" and monetary penalties that would be triple
the amount of payment to physician groups should criminal wrongdoing
be discovered.
More recently, OIG auditors have found that since 1996, fraudulent
and erroneous Medicare payments have been reduced by one-half,
saving taxpayers $11 billion.1 Recently,
HCFA has adopted a softer and gentler tone with respect to health
care fraud investigations. Its new Comprehensive Plan for Program
Integrity has a more conciliatory tone, with the objective to
"pay it right" the first time. HCFA has learned that a partnership
with physicians' groups through education and awareness is the
prime way to prevent health care fraud and inaccurate billing.
In other words, HCFA wants to enlist our help in billing Medicare
and other third-party payers accurately and correctly.
I recently attended a lecture by a special agent from the OIG
here at the Nashville suboffice.2
This lecture was presented to the quarterly Medicare Advisory
Committee. The agent convinced us that their investigations of
physician practices sought blatant criminal activities, not billing
mistakes. I was told of an example of a psychiatrist who billed
Medicare for seeing patients 24 hours a day, 365 days out of a
year. This is an example of unscrupulous billing activity that
commands their attention.
At present, HCFA requires local carriers to investigate (by
audit evaluation of medical records) those procedures that are
more frequent than benchmark average national or regional rates.
For example, if your practice provides monitored anesthesia care
(MAC) more than a nationalized benchmark rate, your practice will
have random audit reviews of MAC procedures. Our local carrier,
Healthcare Integrity Team, investigates suspected cases of fraud
and abuse that may be uncovered by these audits. "All complaints
or tips are thoroughly investigated. Simple misunderstandings,
billing errors or lack of knowledge in billing procedures are
ruled out and corrected. Suspected cases of fraud or abuse are
expanded and resolved or referred to the OIG." 3
Role of the Medicare Advisory Committee
Active involvement in the Medicare Advisory Committee cannot
be overemphasized. HCFA will frequently direct carrier work groups
to institute local medical review policies on various anesthesia
items (for example, MAC, epidural steroid injections, anesthesia
for ocular and oral procedures). These policies will be introduced
in various regions of the country at different times. It is vital
that you have access to the introduction of these policies so
that you have input before your local carrier institutes the policy.
It is also vital that you maintain a good relationship with your
carrier medical director (see pages 2829). Through this
relationship, it is possible to improve these local policies,
make them user friendly and more actively reflect your practice
style. Unfortunately, these local medical review policies receive
very little input from our national society. These policies may
simply reflect the carrier work group's attitude toward reimbursement
for certain procedures.
Anesthesia Billing Ticket and Coding Techniques
When we began compliance activities, it was obvious that
the concept of anesthesia start time was confusing and misunderstood
by the majority of our anesthesia providers. After reviewing HCFA
rules and the Correct Coding Initiative, we began to educate our
providers on exactly when anesthesia start time begins. We found
that we were often missing legally billable anesthesia time. We
also suggest that you examine your process for ICD-9 diagnosis
and CPT procedural coding. We feel the best person to accurately
code is the person in the operating room who is interacting with
the surgeon. Most surgeons have become adept at coding because
they realize reimbursement is directly linked to precise coding.
As you know, the code books require specific detailed information
to which office coders may not have immediate access and would
have difficulty obtaining through operative records and progress
notes. Inaccurate coding can lead to denial of claims and potential
accusations of "upcoding."
Steps to Take to Begin Compliance/Improving Your Billing
Perhaps you have been dragging your feet on getting an anesthesia
compliance program started. Consider trying these simple steps:
- Obtain the ASA document on "Compliance With Medicare
and Other Payor Billing Requirements," published in September
1997.4 This is the best source on
the subject that I have found. Especially note the chapter on
"Pitfalls on Billing Medicare for Anesthesia Services."
- Obtain a copy of the HCFA rules and the Correct Coding
Initiative.
- Establish a relationship with the Medicare carrier
medical director in your region.
- Obtain copies of all the local medical review policies
that have come out in your region in the last three years and
review them.
- Begin a thorough scrutiny of your own billing ticket,
assuring that people understand how to accurately complete it.
- Learn to do your own coding.
Conclusion
Perhaps you can view compliance as a way of applying the same
level of care to the patient's bill that you provide for them
in the operating room. In addition, you will have the peace of
mind that you are in compliance with federal regulatory agencies
regarding billing. You will also be sure that you are capturing
the maximum amount of reimbursement to which you are legally entitled.
References:
1. "Feds Try New Tack for Stopping Fraud."
American Medical News. March 1, 1999.
2. OIG Presentation to Tennessee Medicare
Advisory Committee. January 26, 2000.
3. "Fraud and Abuse: Protecting Your Interest."
CIGNA Healthcare, Tennessee Carrier Advisory Committee Meeting.
January 27, 1999.
4. American Society of Anesthesiologists.
Compliance With Medicare and Other Payor Billing Requirements;
1997.
Paul J. Lipson, M.D., is a partner in Anesthesia
Medical Group, P.C., Nashville, Tennessee, and is a member of
the Tennessee Medicare Advisory Committee, Tennessee Society of
Anesthesiologists.
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