It is a Lewis Black morning
I find it unbelievable that a physician would say such a thing. This is from the OIG link that was provided above. You might want to ask the provider if he is going to start taking all of the training that the OIG is recommending...
Coding and Billing TrainingCoding and billing training on the Federal health care program requirements may be necessary for certain members of the physician practice staff depending on their respective responsibilities. The OIG understands that most physician practices do not employ a professional coder and that the physician is often primarily responsible for all coding and billing. However, it is in the practice's best interest to ensure that individuals who are directly involved with billing, coding or other aspects of the Federal health care programs receive extensive education specific to that individual's responsibilities. Some examples of items that could be covered in coding and billing training include:
• Coding requirements;
• Claim development and submission processes;
• Signing a form for a physician without the physician's authorization;
• Proper documentation of services rendered;
• Proper billing standards and procedures and submission of accurate bills for services or items rendered to Federal health care program beneficiaries; and
• The legal sanctions for submitting deliberately false or reckless billings.
3. Format of the Training Program
Training may be conducted either in-house or by an outside source.37
37 As noted earlier in this guidance, another way for physician practices to receive training is for the physicians and/or the employees of the practice to attend training programs offered by outside entities, such as a hospital, a local medical society or a
Federal Register / Vol. 65, No. 194 / Thursday, October 5, 2000 / Notices 59443
Training at outside seminars, instead of internal programs and in-service sessions, may be an effective way to achieve the practice's training goals. In fact, many community colleges offer certificate or associate degree programs in billing and coding, and professional associations provide various kinds of continuing education and certification programs. Many carriers also offer billing training.
The physician practice may work with its third-party billing company, if one is used, to ensure that documentation is of a level that is adequate for the billing company to submit accurate claims on behalf of the physician practice. If it is not, these problem areas should also be covered in the training. In addition to the billing training, it is advisable for physician practices to maintain updated ICD–9, HCPCS and CPT manuals (in addition to the carrier bulletins construing those sources) and make them available to all employees involved in the billing process. Physician practices can also provide a source of continuous updates on current billing standards and procedures by making publications or Government documents that describe current billing policies available to its employees.38
Physician practices do not have to provide separate education and training programs for the compliance and coding and billing training. All in-service
training and continuing education can integrate compliance issues, as well as other core values adopted by the
practice, such as quality improvement and improved patient service, into their curriculum.
4. Continuing Education on Compliance Issues
There is no set formula for determining how often training sessions should occur. The OIG recommends that there be at least an annual training program for all individuals involved in the coding and billing aspects of the practice.39 Ideally, new billing and
carrier. This sort of collaborative effort is an excellent way for the practice to meet the desired training objective without having to expend the resources to develop and implement in-house training.
38 Some publications, such as OIG's Special Fraud Alerts, audit and inspection reports, and Advisory Opinions are readily available from the OIG and can provide a basis for educational courses and programs for physician practice employees. See Appendix F for a partial listing of these documents. See Footnote 3 for information on how to obtain copies of these documents.
39 Currently, the OIG is monitoring a significant number of corporate integrity agreements that require many of these training elements. The OIG usually requires a minimum of one hour annually for basic training in compliance areas. Additional
coding employees will be trained as soon as possible after assuming their duties and will work under an experienced employee until their training has been completed.
Step Five: Responding To Detected Offenses and Developing Corrective Action Initiatives
When a practice determines it has detected a possible violation, the next step is to develop a corrective action plan and determine how to respond to the problem. Violations of a physician practice's compliance program, significant failures to comply with applicable Federal or State law, and other types of misconduct threaten a practice's status as a reliable, honest, and trustworthy provider of health care. Consequently, upon receipt of reports or reasonable indications of suspected noncompliance, it is important that the compliance contact or other practice employee look into the allegations to determine whether a significant violation of applicable law or the requirements of the compliance program has indeed occurred, and, if so, take decisive steps to correct the problem.40 As appropriate, such steps may involve a corrective action plan,41 the return of any overpayments, a report to the Government,42 and/or a referral to law enforcement authorities.
One suggestion is that the practice, in developing its compliance program, develop its own set of monitors and warning indicators. These might include: Significant changes in the number and/or types of claim rejections and/or reductions; correspondence from
training may be necessary for specialty fields such as claims development and billing.
40 Instances of noncompliance must be determined on a case-by-case basis. The existence or amount of a monetary loss to a health care program is not solely determinative of whether the conduct should be investigated and reported to governmental authorities. In fact, there may be instances where there is no readily identifiable monetary loss to a health care provider, but corrective actions are still necessary to protect the integrity of the applicable program and its beneficiaries, e.g., where services required by a plan of care are not provided.
41 The physician practice may seek advice from its legal counsel to determine the extent of the practice's liability and to plan the appropriate course of action.
42 The OIG has established a Provider Self-Disclosure Protocol that encourages providers to voluntarily report suspected fraud. The concept of voluntary self-disclosure is premised on a recognition that the Government alone cannot protect the integrity of the Medicare and other Federal health care programs. Health care providers must be willing to police themselves, correct underlying problems, and work with the Government to resolve these matters. The Provider Self-Disclosure Protocol can be located on the OIG's web site at:
www.hhs.gov/oig. See Appendix D for further information on the Provider Self-Disclosure Protocol.
the carriers and insurers challenging the medical necessity or validity of claims; illogical patterns or unusual changes in the pattern of CPT–4, HCPCS or ICD–9 code utilization; and high volumes of unusual charge or payment adjustment transactions. If any of these warning indicators become apparent, then it is recommended that the practice follow up on the issues. Subsequently, as appropriate, the compliance procedures of the practice may need to be changed to prevent the problem from recurring.
For potential criminal violations, a physician practice would be well advised in its compliance program procedures to include steps for prompt referral or disclosure to an appropriate Government authority or law enforcement agency. In regard to overpayment issues, it is advised that the physician practice take appropriate corrective action, including prompt identification and repayment of any overpayment to the affected payor.
It is also recommended that the compliance program provide for a full internal assessment of all reports of detected violations. If the physician practice ignores reports of possible fraudulent activity, it is undermining the very purpose it hoped to achieve by implementing a compliance program.
It is advised that the compliance program standards and procedures include provisions to ensure that a violation is not compounded once discovered. In instances involving individual misconduct, the standards and procedures might also advise as to whether the individuals involved in the violation either be retrained, disciplined, or, if appropriate, terminated. The physician practice may also prevent the compounding of the violation by conducting a review of all confirmed violations, and, if appropriate, self-reporting the violations to the applicable authority.
The physician practice may consider the fact that if a violation occurred and was not detected, its compliance program may require modification. Physician practices that detect violations could analyze the situation to determine whether a flaw in their compliance program failed to anticipate the detected problem, or whether the compliance program's procedures failed to prevent the violation. In any event, it is prudent, even absent the detection of any violations, for physician practices to periodically review and modify their compliance programs.
