Risk Assessment of Medical Practice Billing Companies

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Office of Inspector General

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[By Pati Trites MPA, CHBC with Staff Reporters]

The Office of Inspector General [OIG] believes a medical billing company’s written policies and procedures, its educational program and its audit and investigation plans should take into consideration the particular statutes, rules and program instructions that apply to each function or department of the billing company.

Co-ordination Needed

Consequently, coordination between these functions is needed, with an emphasis on areas of special concern that have been identified by the OIG through its investigative and audit functions.

Furthermore, the OIG recommends that billing companies conduct a comprehensive self-administered risk analysis or contract for an independent risk analysis by experienced health care consulting professionals. This risk analysis should identify and rank the various compliance and business risks the company may experience in its daily operations.

Risk Analysis

Once completed, the risk analysis should serve as the basis for the written policies the billing company should develop. The OIG provides the following specific list of particular risk areas that should be addressed by billing companies. It should be noted that this list is not all-encompassing and the risk analysis completed as a result of the company’s audit may provide a more individualized roadmap. Nonetheless, this list is a compilation of several years of OIG audits, investigations and evaluations and should provide a solid starting point for a company’s initial effort.

Problem List

Among the risk areas the OIG has identified as particularly problematic are:

  • Billing for items or services not actually documented;
  • Unbundling;
  • Upcoding, such as, for example, “DRG creep;
  • Inappropriate balance billing;
  • Inadequate resolution of overpayments;
  • Lack of integrity in computer systems;
  • Computer software programs that encourage billing personnel to enter data in fields indicating services were rendered though not actually performed or documented;
  • Failure to maintain the confidentiality of information/records;
  • Knowing misuse of provider identification numbers, which results in improper billing;
  • Outpatient services rendered in connection with inpatient stays;
  • Duplicate billing in an attempt to gain duplicate payment;
  • Billing for discharge in lieu of transfer;
  • Failure to properly use modifiers;
  • Billing company incentives that violate the anti-kickback statute or other similar Federal or State statute or regulation;
  • Joint ventures;
  • Routine waiver of copayments and billing third-party insurance only; and
  • Discounts and professional courtesy.

Additional Risk Areas

The physician-executive should understand that a billing company’s prior history of noncompliance with applicable statutes, regulations and Federal health care program requirements may indicate additional types of risk areas where the billing company may be vulnerable and may require necessary policy measures to prevent avoidable recurrence.

Additional risk areas should be assessed by billing companies as well as incorporated into the written policies and procedures and training elements developed as part of their compliance programs.

Assessment 

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Billing companies that do not code bills should implement policies that require notification to the provider who is coding to implement and follow compliance safeguards with respect to documentation of services rendered.

Moreover, the OIG recommends that billing companies who do not code for their provider clients incorporate in their contractual agreements the provider’s acknowledgment and agreement to address the above coding compliance safeguards.

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OSHA Medical Record Keeping Standards

On the Recording – Reporting of Occupational Injuries and Illness [29 CFR 1904]

By Pati Trites; MPA, CHBC and CPC

tritesIn this era of eHRs, and eMRs, it is vital to understand how OSHAs Recording and Reporting of Occupational Injuries and Illnesses Standard [29 C.F.R. 1904 – also known as the Recordkeeping Standard] requires employers to record & report work-related fatalities, injuries and illnesses www.HealthcareFinancials.com

Exemptions

For example, in January 2001, OSHA provided for a partial exemption from this Standard for many industries including: Offices & Clinics of Medical Doctors, Offices and Clinics of Dentists, Offices of Osteopathic, Offices of Other Health Practitioners, Medical and Dental Laboratories, and Health and Allied Services, Not Elsewhere Classified [1].

The exemption applies as long as the above-stated employers do not have at least one of the following events occur:

  • any workplace incident that results in a fatality; or
  • the hospitalization of three or more employees (example: a malfunctioning heat exchanger on a furnace causes carbon monoxide poisoning to the employees. If three or more must be hospitalized, then the exemption is lost for the calendar year).

If either of these two events occurs then the practice must comply with the reporting requirements of this Standard. Again, each employer who is physically located in one of the 26 states that has its own OSHA must follow state requirements if they are stricter.

Fatality or Hospitalization

In the event of a workplace fatality or an incident that causes the hospitalization of three or more employees, the employer must notify OSHA’s Area Office nearest to the site of the incident either in person or by phone. Notification can also be made by calling the OSHA toll-free central telephone number, 1-800-321-OSHA (1-800-321-6742). This notification must be accomplished within eight hours of the occurrence [2].

OSHA Form 330

Although the likelihood of either of these occurrences taking place is slight, it may be prudent to maintain records that comply with the OSHA Recordkeeping Standard in the event the practice’s partial exemption is lost during a calendar year. Keeping adequate records includes maintaining an OSHA Form 300, which is a log of the following events: days away from work, restricted work or transfer to another job, medical treatment beyond first aid, loss of consciousness, and a significant injury or illness diagnosed by a physician or other licensed healthcare professional.

OSHA Form 330-A

If the practice maintains its partial exemption throughout the calendar year, nothing further needs to be done. But if the practice loses its partial exemption this form must be used to complete a second OSHA form, Form 300A, the annual summary. The employer must post a copy of Form 300A in each practice location (if there are multiple locations) in a conspicuous place or places where notices to employees are customarily posted. The employer must also ensure that the posted annual summary is not altered, defaced, or covered by other material. The Form 300A remains posted from February 1 through April 30 of the calendar year following the year of data collection [3]. In other words, for all records kept in 2005, Form 300A would be posted from February 1, 2006, through April 30, 2006, and so on.

AssessmentMedical Chart

An additional recordkeeping requirement for healthcare entities is established in the Bloodborne Pathogen Standard, wherein the Sharps Injury Log must be maintained by any employer who must comply with the Recordkeeping Standard. If the employer loses his or her partial exemption during the year, then there is an obligation to complete and maintain the Sharps Injury Log. Again, this is a form that probably should be maintained by all healthcare organizations just in case the partial exemption is lost in any particular year.

Conclusion

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1.  29 C.F.R. 1904 Subpart B Appendix A.

2.  29 C.F.R. 1904.39.

3.  29 C.F.R. 1904.32.

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Hand Washing for Healthcare Facilities

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Understanding OSHA Standards

[By Dr. David E. Marcinko; FACFAS, MBA, CPHQ, CMP™]

[By Patricia A. Trites; MPA, CHBC, CHCC, CMP™ (Hon)]

The OSHA Standards for healthcare require that hand washing facilities be readily available to employees.

Definition

Hand washing facilities are defined as a facility providing an adequate supply of:

  • running potable water;
  • antiseptic soap; and
  • single-use disposable towels or hot air drying machines.

Location

The hand washing facilities must be located where the employee will have easy access. This will ensure that the employee will be likely to use the hand washing facility and will minimize the time that the contamination will remain in contact with the employee. In those instances where the provision of hand washing facilities is not feasible, either an appropriate antiseptic hand cleaner (e.g., alcohol-based rinse, antiseptic foam, or antiseptic-impregnated paper wipes) in conjunction with clean cloth or paper towels, or antiseptic towelettes, must be provided.

Soap and Running Water

When using antiseptic hand cleansers or towelettes, the hands must be washed with soap and running water as soon as feasible. Not only must the employer provide the hand washing facilities, he or she must also ensure that employees in fact do wash their hands immediately or as soon as feasible following contact with blood or other potentially infectious material [OPIM].

The employee must also wash his or her hands immediately after removal of gloves or other personal protective equipment [PPE]. It is the employer’s responsibility to ensure that hand washing occurs. OSHA states that hand washing must be strictly enforced by the employer.

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Assessment

How has OSHA affected your hospital, medical practice or healthcare facility?

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Conclusion

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On Baseline Medical Practice Compliance Audits

Establishing a Reference Point is Key to Success

Submitted by Pati Trites; MPA, CHBC with Staff Reporters 

www.HealthcareFinancials.comho-journal11

There are several types of compliance audits that a medical practice, clinic or healthcare organization might need to perform. The starting point is to obtain a baseline audit. The next step, discussed elsewhere on this ME-P, is periodic audits or reviews that are performed after information is obtained from the baseline audit.

Baseline Audits

Baseline audits are preliminary assessments to develop a reference point. Until a medical practice or healthcare organization establishes a track record with items such as coding accuracy or documentation to support medical necessity, it is difficult to determine any performance issues. In the spirit of Total Quality Management [TQM], the information that is shared should be done in a non-punitive manner to demonstrate that the intent of the process is to create a positive environment geared towards fixing the problems. A baseline audit can help any organization understand where the program is and establish a reference for future activities.

Assessment

Additional audits can also be performed whenever new employees are added, or if there are complaints, or issues that arise in the course of business.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated? Have you ever discovered an untoward past event, or interesting prior fact, with your baseline audit?

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Understanding the Emergency Medical Treatment and Active Labor Act

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An Important and Contemporary Issue – Once Again

[By Patricia Trites; MPA, CHBC, CMP™ (Hon) with Staff Reporters]

tritesThe Emergency Medical Treatment and Active Labor Act (EMTALA) is receiving increasing scrutiny from prosecutors during these times of financials stress and credit tightening. The statute is intended to ensure that all patients who come to the emergency department of a hospital receive care, regardless of their insurance or ability to pay. Both hospitals and physicians need to work together to ensure compliance with the provisions of this law.

Triad of Requirements

EMTALA imposes three fundamental requirements upon hospitals that participate in the Medicare program with regard to patients requesting emergency care.

First, the hospital must conduct an appropriate medical screening examination to determine if an emergency medical condition exists.

Second, if the hospital determines that an emergency medical condition exists, it must either provide the treatment necessary to stabilize the emergency medical condition or comply with the statute’s requirements to affect a proper transfer of a patient whose condition has not been stabilized. A hospital is considered to have met this second requirement if an individual refuses the hospital’s offer of additional examination or treatment, or refuses to consent to a transfer, after having been informed of the risks and benefits of treatment.

Third, EMTALA’s requirement is activated if an individual’s emergency medical condition has not been stabilized.

Hospital Transfers

A hospital may not transfer an individual with an unstable emergency medical condition unless:

(1) the individual or his or her representative makes a written request for transfer to another medical facility after being informed of the risk of transfer and the transferring hospital’s obligation under the statute to provide additional examination or treatment;

(2) a physician has signed a certification summarizing the medical risks and benefits of a transfer and certifying that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the transfer outweigh the increased risks; or

(3) a qualified medical person signs the certification after the physician, in consultation with the qualified medical person, has made the determination that the benefits of transfer outweigh the increased risks, if a physician is not physically present when the transfer decision is made. The physician must later countersign the certification.dhimc-book21

On-Call Responsibilities

One area of particular concern is physician on-call responsibilities. Physician practices whose members serve as on-call hospital emergency room physicians are advised to familiarize themselves with the hospital’s policies regarding on-call physicians. This can be done by reviewing the medical staff bylaws or policies and procedures of the hospital that must define the responsibility of on-call physicians to respond to, examine, and treat patients with emergency medical conditions. Physicians should also be aware of the requirement that, when medically indicated, on-call physicians must generally come to the hospital to examine the patient. Patients may be sent to see the on-call physician at a hospital-owned contiguous or on-campus facility to conduct or complete the medical screening examination due to the following reasons:

  • all persons with the same medical condition are moved to this location;
  • there is a bona fide medical reason to move the patient;
  • qualified medical personnel accompany the patient; and
  • teaching physicians may participate.

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Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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