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Averting Audits: Part 3

Compliance programs can prevent a CMS billing review or help your case

APRIL JASPER, O.D.

In “Averting Audits: Part 1 and 2,” respectively, I discussed the importance of validating and scrutinizing any procedure you intend to bill to third party carriers and the significance of ensuring your EHR doesn’t place your practice at risk for a billing review.

Here, in the final installment, I talk about how a compliance program can preclude audits or assist with an appeal and what a program should include.

Compliance programs

These programs demonstrate to CMS your intent to adhere to all their requirements for reimbursement. Although they are not guaranteed “get-out-of-jail-free” cards in the event of an audit, they do show a desire for a culture of compliance — which has the potential to help a doctor under a billing review.

“CMS believes that compliance efforts are fundamentally designed to establish a culture within an organization that promotes the prevention, detection and resolution of instances of conduct that do not conform to federal and state law, or to federal healthcare program requirements . . . ,” reveals the CMS Compliance Program Guide (see http://bit.ly/1Cyq1d0). “It is critical for the Medicare fee-for-service contractor to assess its own organization and determine its needs with regard to compliance with applicable federal and state statutes and federal healthcare program requirements.”

Program structure

Based on the CMS Compliance Program Guide, a program is comprised of:

▶ Written policies to prevent the employment and contract of unlawful individuals. For example, you may want to enforce background checks to rule out previous criminal convictions, suspensions or debarment from federal program participation.

▶ Written standards of conduct. These state your commitment to comply to all CMS contract requirements. It should be clearly written, and every employee should be required to read and sign it, acknowledging understanding and agreement.

▶ Designation of a compliance officer or committee.

▶ Written policies and procedures. These should be developed by the established compliance officer or committee and should include, but not be limited to, (a) duties and responsibilities of the compliance officer and/or committee, (b) training process for employees to ensure compliance with policies, (c) guidelines for internal audits and (d) a policy for background screenings of current and prospective employees.

▶ Written policy for record retention. Base the policy on CMS rules.

▶ Effective training and education in general compliance with CMS policies and standards. Document every training program your employees attend, make it your practice’s policy to have regular and required compliance training sessions, and sign certifications that staff have completed the required training. CMS suggests that initial training should occur for new employees at or very near their hire date, and refresher training should take place at least yearly.

▶ Written policy for including compliance in employee performance plan. Doing so shows CMS that compliance is, indeed, a major focus of your practice.

▶ Communication encouragement. Create an effective means of galvanizing all employees to come forward if they see or suspect any variation from compliance requirements.

▶ Completion of a comprehensive internal audit. The audit should be performed by someone who is not on your billing team. If this isn’t possible, consider hiring an outside contractor. The audit should include areas where improvement is needed, as well as the corrective steps in each case to encourage better compliance.

▶ Responses to offense. This should list the consequences, such as disciplinary action or reporting the offense to the appropriate government authorities.

A final layer of protection

Establishing a compliance program, as recommended by CMS, is the third and final step in averting audits and ensuring proper billing and documentation procedures. Most small optometric practices have this outsourced. OM

DR. JASPER IS A VISION SOURCE ADMINISTRATOR AND IN PRIVATE PRACTICE IN WEST PALM BEACH, FLA. E-MAIL HER AT DRJASPER@AESWPB.COM, OR COMMENT AT OPTOMETRICMANAGEMENT@GMAIL.COM.