During my 24 years in the health care industry focusing on compliance, I often get asked the same question by my fellow chiropractors: “Why would I need a consultant?”
The long answer is that a compliance consultant who is a certified compliance specialist can help you navigate the tricky world of HIPAA Omnibus Privacy Rules, regulatory compliance, ICD-10 coding, PQRS, compliance training, and a host of other compliance services you and your staff must manage on a daily basis.
But the short answer usually makes my case. You should get a compliance consultant before the Office of the Inspector General for the Department of Health and Human Services comes knocking. This applies to CASH practices as well…if you don’t think so checkout “The OIG Compliance Program Blue Print, As Mandated By Law, For ALL Doctors Of Chiropractic “.
The Office of the Inspector General, or OIG, has oversight authority for everything related to Medicare, and it recently released its Fiscal Year 2013 Work Plan that details how it will review and handle Medicare Part B payments. The plan states Medicare-covered chiropractic services should include only treatment by means of manual manipulation of the spine to correct subluxations, and that chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable. It emphasizes in no uncertain terms that Medicare will not pay for items or services that are “not reasonable and necessary.”
When you accept Medicare payments, or even bill Medicare as a non-participating provider (which you are required to do for your Medicare patients), you agree to oversight by the OIG, which can include an audit. That means they have the right to enter your office and review any records they see fit without the need for a warrant or patient permission per HIPAA guidelines. The OIG also can search historical data, going as far back as the day you opened your doors if it has a reasonable suspicion of fraud.
Refusal to cooperate can mean a more detailed audit and large headaches. So it’s important to arm yourself with the right information. The following details what an OIG audit typically entails and how you can survive it.
The Anatomy of an Audit
When the OIG auditor arrives, he or she will request to see your compliance program manual and use a computer program to randomly select dates of service. He or she then will scan selected medical records to examine your paid Medicare claims later at their offices.
You might find yourself thinking, “That doesn’t sound so bad.” Trust me, it is that bad.
If the OIG discovers instances of overpayment, it will attempt to recover those funds and initiate further reviews. The slightest hint of fraud will trigger more examinations and possibly even a full onsite audit of your office, which involves an army of auditors that comb through all of your Medicare records. Worst of all, this process can take days and massively disrupt your practice.
Additionally, the audit process itself is flawed. The random sampling methodology often does not take into account the full picture of a patient’s treatment and its benefits.
For example, the selected dates might not cover initial visits or re-exams and instead focus on subsequent appointments in which you were carrying out the treatment plan. That’s like looking at treatment notes developed after taking the seventh pill in a 40-pill course of antibiotics. These snapshots are incomplete at best and misleading at worst.
Take Action
If you win the Inspector General lottery, first of all, don’t panic. Your most important moves at this stage are to develop a plan and seek help.
First, you should learn this phrase: “Silence is golden.” Our first impulse is always to explain ourselves, but you should remain quiet. Don’t offer any unsolicited information to the investigators. Too many simple reviews have turned into full-blown audits because a doctor tried to explain the situation.
Second, you should find professionals to walk you through this process. A compliance consultant who understands the Medicare system and has worked with the OIG is a good advocate. The consultant may refer you to an attorney licensed in your state that specializes in Medicare regulatory issues*. When you hire the attorney, he or she will place your consultant under privilege, which prevents the OIG from compelling testimony from the person you hired to protect you. This step is important because it allows you to be completely open with your consultant.
* (We will further discuss the issues surrounding hiring an attorney in a future blog post.)
One day before the OIG’s scheduled visit, your compliance consultant should visit your office. They will meet with you and your staff to review and explain the situation. This audit is not a secret to be kept from your staff, and you will need their help in calling patients to cancel appointments scheduled for the audit days. You will want your office to be patient-free when the auditors are there.
Next, you should select a single staff member to work with your compliance consultant when the OIG is in the office. Everyone else should be given the day off. During this pre-planning, your compliance consultant will be communicating directly with the OIG and determining when and how long they will speak to you during a face-to-face interview.
During this initial review, the compliance consultant should get the names and dates of the requested files. Your designated staff member should then retrieve those records and have them ready for the auditor. This limits the OIG from having direct access to your files. Your staffer also should copy each record requested by the OIG for use by the consultant and your attorney later.
It also may be smart to have your compliance consultant do a “shadow review” of all the requested records. In this assessment, your consultant will evaluate all of the records OIG copied under the harshest criteria possible to determine a worst-case scenario. This “shadow review” can provide valuable information for future negotiations with the OIG should it demand a refund.
Limit your Exposure
When you finally speak with the OIG’s auditor, make sure your compliance consultant is present to monitor the proceedings. If the discussion veers into a direction that could be harmful to you, the compliance consultant should suggest a postponement until your attorney can be present or that any additional questions be first submitted in writing.
You want to maintain control of the situation, and limit the exposure you, your staff and your records have to OIG auditors. For example, these investigators have been known to visit the homes of staff members to interview them. You cannot instruct your staff to refuse their questioning—that’s obstruction, and it can get you in trouble. However, you can inform your staff they have the right to decline a conversation with OIG personnel. Additionally, your staff also has the right to set the time and place of any interview, as well as have their personal lawyers present for questioning.
An Insurance Policy
Medical Compliance Specialists and lawyers may sound expensive, but their fees pale in comparison to the financial punishment the OIG could levy against you.
The Inspector General can issue fines of up to $10,000 per occurrence of fraud and abuse, so utilizing a third party to help insulate your practice may be a smart investment. Think of it as a low-cost insurance plan, and some malpractice carriers will even cover some of those costs under certain circumstances.
It’s Your Choice
Prevention is the key word here. Why put yourself thought the fear and stress of losing everything you’ve worked hard for when it doesn’t have to be that way.
Just sitting back, living with the worry hanging over your head and then kicking your ass later for being so foolish is not acceptable! For those of you who tend to put things off and you know who you are, I have easy solutions for you.
You can do it yourself with “Chiropractic Compliance Made Easy,” the complete office compliance system, or become a Chiropractic Auditing Services member by calling our office and we’ll do it for you. So there’s no excuse.
As a member you get to become one of the growing number of doctors who have stepped up and done the right thing for themselves and as a result are fully confident about compliance and experiencing the joy of healing people without fear.
One of the most common areas for increased scrutiny by Medicare and private insurance are the E/M codes. Most doctors don’t understand them, causing mistakes.
As a healthcare provider, much of the Electronic Protected Health Information (ePHI) you maintain and share with other entities is crucial to your business and important in the care you provide to your patients.
Are you using computers that run on Windows XP in your office? If you are you may be violating HIPAA laws by doing so.
In my last post, I talked about the steps you should take if the Office of Inspector General for the U.S.Department of Health and Human Services selects your practice for a Medicare reimbursement audit.
