Planning Strategies
Sharpen Your Billing Compliance
Don't run the risk of being sanctioned. These tips will keep you out of trouble.

Most physicians have no idea that a person who's found guilty of committing Medicare fraud faces a host of different criminal, civil and administrative sanctions and penalties that can include:

• civil penalties of $5,000 to $10,000 per false claim and treble damages under the False Claims Act
• criminal fines and/or imprisonment of up to 10 years if convicted of the crime of Health Care Fraud as provided for in the Health Insurance Portability and Accountability Act of 1996 or -- for violations of the Medicare/Medicaid Anti-Kickback Statute -- imprisonment of up to 5 years, and/or a criminal fine of up to $25,000
• administrative sanctions up to a $10,000 civil monetary penalty per line item on a false claim, assessments of up to treble the amount falsely claimed, and/or exclusion from participation in Medicare and state healthcare programs.

THERE'S NO MAGIC FORMULA

With such severe penalties looming over physicians who run afoul of government regulators, it would be wonderful if you could purchase a software program that would ensure you got paid for the work you've done and keep your practice in absolute compliance with all coding and compliance regulations.

Unfortunately, that software program doesn't yet exist. But don't despair. In this article, I'll point out several other ways to improve billing compliance in your office.

If you're like the majority of physicians, your goal is to institute a billing system that's fair to both you and your payers. That's an achievable aim.

Bryn J. Henderson, D.O., a principal in Healthworxx, based in Orange, Calif., uses proprietary software to assist medical practices in improving their billing compliance. Practices send Healthworxx their monthly data on the procedures they've performed and the codes they've assigned to specific procedures. Healthworxx sends back a report identifying areas where potential compliance problems may exist.

YOU CAN'T FOOL THE SYSTEM

"Some practices try to 'game' the system," says Dr. Henderson. "They'll have a patient make more visits than are actually required, or they'll make it look as if the patient is sicker than he really is, or they'll unbundle services that should be listed under a single claim. The problem for these practices is that the payers are wise to all of these games, so the red flags go up immediately."

Henderson says many doctors are unaware that their practice's billing procedures are putting them in jeopardy.

"My experience is that most doctors will read everything they can when it comes to obtaining clinical knowledge, but they'll leave all the details of billing to their staff. They have to realize that it's their license that's on the line."

BE AWARE OF "RED FLAGS"

Compliance specialists say physicians should regularly review their practice's billing procedures. You should get more deeply involved, especially if any of the following red flags are raised:

• significant recoding by payers of claims submitted by your practice
• greater scrutiny by payers in authorizing your claims
• a payer audit of your claims.

These warning signals are often a prelude to a federal investigation by the Office of the Inspector General (OIG).

If you find the coding and billing compliance process too daunting to handle internally, hire an outside consultant. These specialists will provide you with services that range from conducting an on-site evaluation of your billing procedures, to supplying you with accurate codes for specific procedures, to monitoring changes in payer billing codes.

Consultants can do more than save you from sanctions. By knowing what you must do to meet the requirements of each specific code, they can also reduce your number of denied claims, increase your revenue and help accelerate the reimbursement process. 

Dr. Gable is chief executive officer of Dynamic Health Connections, Inc., in Lake Forest, Calif., which provides specialized consulting expertise for subspecialty physician groups, managed care organizations and other medical organizations. You can reach him at dhc38@aol.com.