Physiatry Practice Management Resources

Few could blame physicians for believing we are headed back to George Orwell's "1984" rather than forward to the millennium. The Federal Government's initiative calling on patients to report suspected instances of Medicare fraud on the part of their physicians to the Feds is the newest engine powering "Big Brother."

What's particularly galling to physicians is the way the initiative is being marketed to the public, according to practice-management consultant Owen J. Dahl, president of SALCO in New Orleans. Mr. Dahl points out that patients are being told they can make money by turning in their doctors. If fraud is proven, one-third of the amount is "kicked back" to the reporting patient.

Supported by AARP

The initiative enjoys the strong backing and active encouragement of the American Association of Retired Persons (AARP). This organization's literature encourages its members to call the Medicare fraud hotline, if, after reviewing their bills, they can't answer "yes" to the following questions:

• Did you receive the service or product for which Medicare is being billed?
• Did your doctor order the service or product for you?
• Is the service or product relevant to your diagnosis or treatment?

All physicians who bill Medicare are at risk of having patients turn them in for alleged fraud. However, practices in internal medicine, cardiology, ophthalmology and orthopedics, with greater numbers of Medicare patients, may be particularly vulnerable, according to Dorothy R. Sweeney, vice president of The Health Care Group, a practice-management consulting firm in Plymouth Meeting, Pa. "These specialties have been the targets of previous fraud initiatives," she says.

Jay Sanders, managing partner in Professional Business Consultants in Oak Brook, Ill., says all specialties are vulnerable, even pediatrics. "The bigger the practice and the more Medicare it handles, the greater the risk of a patient calling the Medicare fraud hotline," he adds. "It's a matter of numbers."

There is no doubt there are fraudulent billings and acts, notes Mr. Dahl. However, honest physicians need not remain passive and hope their patients don't misinterpret or fail to understand their bills and then reach for the telephone to call the Health Care Financing Administration's Medicare-fraud hotline. Rather, physicians should deploy two basic strategies to lessen the risk of being called on the carpet by HCFA.

The first strategy is to recognize the reasons why physicians get accused of committing Medicare fraud. The second strategy is to put procedures in place to head off these accusations.

Coding and Documentation

One of the most common sources of fraud accusations involves upcoding, or "coding at a higher level of service than your documentation will support," says Mr. Sanders. "HCFA likes to see a bell-shaped curve with respect to coding levels."

If a physician only has level 3 and level 4 visits, it raises a red flag, notes Ms. Sweeney. And, the flag will remain red if the physician's charts don't contain adequate documentation justifying each level of service.

The old saw, "If it isn't written, it didn't happen," applies when it comes to documentation. Physicians who claim they are too busy to fully document every chart will find their arguments get short shrift during a Medicare audit.

Ms. Sweeney reports physicians who are of the "I've always done it this way, why should I change" philosophy, or those who insist, "I can understand the chart and why the care was necessary -- surely the Medicare auditor will," are taking considerable risks.

Ignorance of Medicare guidelines also causes physicians problems. For example, says Mr. Dahl, a physician may determine that it is medically necessary to see a patient in a skilled nursing facility three or four times a week. However, if Medicare only permits two visits, the physician could be accused of overbilling. It doesn't matter if the physician thought he or she was just practicing good medicine, he points out.

Unbundling is a third area in which physicians can run afoul of Medicare regulations, points out Mr. Sanders. He uses, as an example, gallbladder surgery. The surgeon who bills Medicare separately (or unbundles) for the gallbladder surgery and exploration of the abdomen is courting trouble.

Mr. Sanders tells of one attorney who studies the practice patterns of an entire group when looking for coding violations. Using the above example, if three of four physicians in the group don't include a separate charge to Medicare for exploring the abdomen, and the fourth physician does, this physician will stick out like a sore thumb and have a lot of explaining to do.

All three consultants believe compliance plans are the backbone of the second strategy -- implementing office procedures and policies to minimize the risk of being accused by patients of Medicare fraud.

The plan should have a compliance officer, says Mr. Dahl. And, he stresses, every practice -- big or small -- should have one. This person should periodically review charts to see if the billings are correct, adds Mr. Sanders. He suggests that the compliance officer randomly pull 10 charts to see if they would stand up to a Medicare audit. The charts should be checked for proper coding and documentation.

Mr. Dahl emphasizes that the compliance officer must have the power to report problems to the governing body or ownership of the practice. The goal is to bring about changes in a practice's way of doing things and, thereby, reduce the chance of an adverse finding during a Medicare audit.

"It's crucial that a compliance plan changes those behaviors by physicians and staff that are not in the best interests of the practice," says Mr. Dahl. "This can't happen if the compliance officer is unable to bring problems to the attention of those in the practice who are in the best position to bring about change."

Ms. Sweeney adds: "The compliance officer should work with physicians who have billing problems. If the problems are severe, a coding expert or consultant should be brought in to the practice to correct deficiencies."

Education is the second component of a compliance plan, notes Mr. Dahl. Education in the form of in-office tutorials or off-site seminars should be available to physicians and staff.

"You don't have to jump on the bandwagon and bring in outside consultants to educate the physicians in the practice and staff," says Mr. Dahl. "It may simply mean that physician A 'audits' B and physician B 'audits' physician C, and so on."

Patient Relations

There are other things practices can do to avoid accusations of Medicare fraud.

"Each practice should designate someone in the billing department that Medicare patients can call directly with problems and questions," says Ms. Sweeney. "That person's name and phone number should be on all bills."

She also recommends that each practice create a pamphlet for patients that explains Medicare billing. "Particular attention should be given to explanations of billings for non-routine office visits and services, including lab tests and medications," she says.

One strategy physicians should not overlook with respect to the new Medicare-fraud initiative is building doctor-patient rapport. Mr. Sanders notes that malpractice defense strategies are instructive here. Time and time again it has been shown that physicians who enjoy good rapport with their patients get sued less often than those with bad rapport. All three consultants believe the same will hold true when it comes to accusations of Medicare fraud.

"The disgruntled patient is more likely to bring charges of Medicare fraud than the patient who is pleased with the care he or she is receiving," says Ms. Sweeney.

"It's important that you remain open to the patient," adds Mr. Dahl. "Talk with him or her about your practice's Medicare billing policies and procedures."

Ms. Sweeney believes that physicians and their staffs will continue to field more questions from their patients about billing as a result of the Medicare-fraud initiative. How they handle these questions may ultimately determine whether or not their practices look forward to the millennium or enter a scary brave new world.

Written by: Bob Feigenbaum