Compliance and documentation: Lessons learned

By Bradley Reiner

I’ve been a practice management consultant for 13 years. I worked 10 years for the Texas Medical Association. I’ve been a contract administrator and still have that role today. I review cases for the Texas Medical Board and I’m endorsed by TAFP. Over the last 20 years, I’ve seen significant changes in health care, but the most dramatic compliance changes have occurred in the last couple of years. The auditing efforts of the state and federal government as well as managed care plans have significantly increased. RACs, ZPICs, and MICs are dominating discussion. Throw in HIPAA, OSHA, and CLIA and you have so many acronyms and issues to contend with every day. Unfortunately these things are not going away. So you find yourself asking, what can you do?

I’m not one to jump on any bandwagon when it comes to these things. In fact, when HIPAA first came out in 2003, I was skeptical about implementing so many policies and procedures if they were going to sit on the shelf gathering dust with no one monitoring them. I had the same feeling initially with OSHA and CLIA. As long as you had a system that was consistent, ethical, appropriate, and legal, why would you waste time and money to have every single policy in writing? It seemed to be nothing more than an easy way for vendors to make money. Documentation and coding was no different. I figured if physicians documented based on the services provided and ensured due diligence, they would be protected. Besides, nobody was really watching these guidelines anyway. Wow, what a big difference a few years can make.

Don’t get me wrong, I believe that compliance is important and I have always counseled the practices I’ve helped to maintain excellent compliance. Realistically, how can any practice be expected to keep track of all of these things and do it correctly every single time? Whether we think it can be done or not is irrelevant. Insurance companies and regulatory agencies expect it now more than ever.

With the potential opportunity to recover millions of dollars in improper payments, documentation and coding have taken center stage. All types of insurance plans—managed care, state, and federal programs—as well as patients are beginning to advocate for compliance.

Don’t Skimp

So when should you begin a full-scale compliance plan to ensure your practice is protected and doing all it can to reduce documentation and coding weaknesses? Can you start on it yesterday? While you are working on that, here are my “don’t skimp” items every practice should consider when establishing a compliance plan.

1. Don’t skimp on compliance policies.
   You need clear documentation of your policies and procedures. There are a number of sources for developing compliance strategies and plans for your practice. Your Academy has policies and procedures that can be downloaded and implemented. Another source to consider reviewing is the OIG’s compliance program for individual and small group practices. This is a seven-step process for implementing compliance in your practice. These days you must ensure that you have a policy and procedure for everything you do as well as plans for how you correct problems when discovered. These processes will help protect your practice.
    
2. Don’t skimp on understanding proper documentation.
   Many physicians don’t even realize there are guidelines, developed by the AMA and CMS, for proper documentation of evaluation and management services. There are two guidelines for doctors to use, 1995 and 1997. More practices use the 1997 guidelines because the information is more detailed. Including detailed information in your record is better than not having enough documentation. You must make sure it’s consistent with the nature of the presenting problem.
    
3. Don’t skimp on understanding coding specifics.
   Many physicians don’t even realize there are guidelines, developed by the AMA and CMS, for proper documentation of evaluation and management services. There are two guidelines for doctors to use, 1995 and 1997. More practices use the 1997 guidelines because the information is more detailed. Including detailed information in your record is better than not having enough documentation. You must make sure it’s consistent with the nature of the presenting problem.
    
4. Don’t skimp on external auditing.
   Have you ever had an outside party review your records to determine if your documentation is in compliance? If you haven’t had this done you should consider hiring someone to complete an audit. What you find may amaze you. Documentation errors and misunderstandings about the guidelines can be corrected, but if no one is monitoring, the same errors will continue to occur. This can lead to huge overpayments which cause insurance audits that necessitate refunds. It’s not a matter of if you will be audited, it’s when.
    
5. Don’t skimp on staff.
   Make sure you have intelligent and knowledgeable staff. This cannot be emphasized enough. Staff often make or break a practice. Billing staff must have a strong billing background with coding experience. Compliance issues can cost thousands of dollars and good staff can help you avoid these problems. If you have good staff, compensate them well so they won’t leave for greener pastures.
    
6. Don’t skimp on self-disclosure.
   If you find something wrong, document it based on your compliance plan and refund any amounts overpaid. Don’t wait for insurance companies to find problems. If they discover problems things could end up being much worse. Be proactive while maintaining compliance. This will impact your practice in many positive ways even if you are audited.
    
7. Don’t skimp on education and training.
   Doctors and staff need continual education and training. Once you have completed an independent audit, investigate any problems needing correction. Train doctors and staff on the concerns and steps necessary to improve. Follow up to ensure the issues have been corrected. Then train again. This training will help the practice meet its obligations of sound compliance strategies while correcting problems.
    
8. Don’t skimp on admitting when you make mistakes.
   Don’t ignore problems. Take whatever actions are necessary to correct the problem. You will sleep better at night.

Compliance and documentation go hand in hand. Implement procedures and policies to help protect your practice against insurance companies and their associated audits. A little bit of effort will be worth the trouble. Follow these few simple suggestions and I am certain you will be happy you did.