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CAN SAVE DOCS TROUBLE By Dr. Smith is a physician in a small group practice of neurologists. She and her partners are constantly referring patients to hospitals and other outside entities for various diagnostic tests, such as MRIs. Her group knows that these outside entities are able to generate significant revenue as the result of these referrals, and they think, "We're the ones making these referrals, so why can't we get a share of that revenue?" They find a hospital that is willing to enter into a "consulting relationship" in which the group receives a significant yearly payment for advising the hospital on various issues. The problem is, no physician in Dr. Smith's group actually provides any consulting services to the hospital. However, the group does begin to send all of its patients to the hospital for diagnostic tests. Late one Friday afternoon, as Dr. Smith is getting ready to take a well-deserved weekend off, FBI agents arrive at her office with a search warrant. She and the other physicians in her group are charged with federal felonies and subsequently convicted. While this account is fictional, the increasing danger of physicians suffering criminal and civil penalties relating to their business practices and billing is real. The Office of Inspector General of the U.S. Department of Health and Human Services reports that criminal convictions relating to government health care programs increased by 20% in 1997, another 16% in 1998, and nearly 54% more in 1999. The Inspector General further reports that its toll-free fraud reporting hotline (800-HHS-TIPS) receives about 11,000 calls per week from Medicare beneficiaries and other outside parties. What can a physician group do to mitigate this danger? One option is the adoption of a compliance program designed to maintain the physician group's compliance with the various laws and regulations that apply to the way it does business. Last month, the Inspector General published its Draft Compliance Guidance for Individual and Small Group Physician Practices. This document sets out the steps that the federal government believes are necessary for a physician or physician group to create a compliance program that steers the group clear of legal violations. It was published in draft form, and the Inspector General is accepting comments on it until July 27. If a physician group adopts an effective compliance plan, it may reap benefits that include a potential for reduced civil or criminal penalties in the event that a problem arises; the detection and resolution of problems before a government investigation commences; a reduction in claim denial by third-party payors; improved medical record documentation; and an increased understanding of how the group's internal processes operate. What is an "effective" compliance plan? While the Inspector General recognizes that there is no "one size fits all" plan, it stresses that whatever plan a physician group eventually adopts must actually be followed. There are seven basic elements that a compliance program should contain:
Risk areas that potentially affect all physician groups include billing for items or services not rendered, or billing for a higher level of service than was actually rendered; submitting claims for items or services that are not medically necessary; submitting multiple claims for a single service; or unbundling bills (for example, separately billing the components of a procedure that should be billed together). This compliance program comes on the heels of similar compliance guides the Inspector General has published for other health care providers, including hospitals, nursing facilities, and billing companies. Physician groups should review the OIG's guidance, and should consider what steps toward compliance are appropriate to their own unique circumstances.
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