Practice Management Alert

3 easy expert moves to tackle and prevent this high-risk  compliance hot spot.

Attention, All Billers: Over-ordering certain diagnostic tests and other services can trigger an audit, but you won't have to worry if you know how to handle this compliance hot spot.

Over-ordering of certain tests and procedures is a high-liability risk because it's identifiable by computer audit, says Wayne J. Miller, attorney with the Compliance Law Group in Los Angeles. The HHS Office of the Inspector General or Medicare can easily identify numbers of ordered tests and procedures that exceed the normal range for your practice, says Miller, who spoke at a recent teleconference on guarding against biller liability.

Medicare creates a detailed profile of every provider showing the quantity of each service, test and procedure the practice orders during the year. Medicare is quick to investigate any time a practice bills for more than its yearly average of a certain service. Something as simple as a shift in your patient base and/or the number of specific services you report can therefore trigger an investigation.

Documentation Is Key

A well-documented medical chart will provide the ammunition you need to fend off accusations. Documentation of medical necessity is what it all comes down to, says Steven Verno, NREMTP, CMBSI, compliance director for the Medical Association of Billers based in Las Vegas. To rule out a medical problem, a physician may need to order a number of diagnostic tests that turn out to be unnecessary. This is justified as long as the patient exhibited the proper signs and symptoms to warrant tests to determine the definitive diagnosis, Verno says.

For example, a patient with chest pain and difficulty breathing enters an emergency department, so the doctor suspects heart trouble and orders an EKG and blood tests. After more tests, the doctor determines the patient has a gastric ulcer but no heart problems. Medicare may say the doctor was over-ordering, based on the final diagnosis, but the medical record will reveal that the tests were necessary because of the patient's signs and symptoms.

Typically, a physician suspected of over-ordering has no fraudulent intent, Verno says. Patient lawsuits often assert that the doctor should have done more tests, therefore providers walk a fine line by trying to cover all the bases yet not go to excess.

Arm against over-ordering charges with these simple steps:

1. Insist on adequate documentation. Never underestimate the importance of documentation, Verno says. Make sure your doctors know to document the signs and symptoms to support every service, test and procedure ordered.

2. Be a watchdog for your practice. Voice your concern if you discover services billed without adequate supporting documentation. A physician may be knowingly or unknowingly trying to bill for unjustified procedures. Either way, as a biller or coder, you are responsible for tactfully addressing the problem and seeing that it is resolved. Be sure to protect yourself from liability by documenting the actions you took to fix the problem.

3. Keep your cool if you're audited. Don't panic if your office receives "the letter" from Medicare requesting to see 25 specific medical records. This is how Medicare conducts its preliminary investigation for over-ordering. Remember that all sorts of factors can alter your ordering and prompt an audit. You're in the clear as long as the charts show adequate medical necessity for services rendered.

Think over-ordering isn't something to take seriously? See Compliance News Update.

For more information on guarding against your biller liability, see Don't Leave Yourself Liable in the January 2004 issue, Vol. 4, No. 1.