Conflict of Interest?


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I've researched this question and I'm unable to find an answer.

We have 2 Compliance Specialist that audit (IP/OP) E/M encounters for the providers where they work. It's their job to change the LOS assigned by the provider depending on the EHR documentation. As you know, this often involves changing the providers E/M LOS (for which they work) to a higher LOS than originally assigned by the provider.

Is it a conflict of interest for the Compliance Specialist to also enter the charges for the records she has audited or should the charges be entered by another department/staff member who it not in a Compliance/Auditor role?



True Blue
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I don't see a conflict of interest here just based on what you've said. Normally the only way there could be a conflict would be if the person doing the auditing stood to gain financially from coding or charging something at a higher level of service. If that were the case, then it could be argued that there was an incentive that could potentially influence their coding and auditing decision. I can't imagine that's the case in this situation - providers may have their pay tied to RVUs, but employees paid on an hourly or salary basis don't have any incentive to code something one way or another.


Brooklyn, New York
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Control Issue

I agree that compliance personnel entering charges is not necessarily a conflict of interest. However I have a couple of concerns with it. One is loss of control over the revenue cycle process. Too many hands touching that process particularly changing financial classes and CPT/I-10 codes and resulting charges can present management control issues. My preference is that compliance personnel only touch the billing system to do inquiries about accounts they are auditing. But I realize that not every facility has the staffing to do this.

But it raises an interesting question in terms of what processes should be out of bounds for compliance personnel. I've seen cases where compliance personnel because they are often very experienced coders are asked to do coding projects. I lean toward feeling that is OK as long as there is a clear separation of responsibilities. But I do think for the most part compliance departments should stick to compliance audits/training etc to avoid the question of compliance compliance.

Jim S.