Today's Practice: Changing the Business of Medicine National Edition Q1 2018 | Page 63

7 Keys to Medicare Defense
Stephen D. Bittinger
mistakenly bills their midlevel services under your NPI
fulltime during the same week. Nothing makes a
data-miner smile more than finding a physician who
appears to be working 200 hours a week based on the
codes coming through the pipe.
Secondly, the scrutiny of billing midlevel providers’
services “incident-to” a physician has been reaching
epidemic proportions. Yes, hospitals and large
multispecialty groups have the software protocols and
compliance teams to perhaps get away with justifying
the risk of billing “incident-to” for another 15% bump
on reimbursement, but very few private practices can
actually meet the stringent requirements. The best bet
is to find another way to increase your margin and stop
waiving the red flag in front of the bull.
2. Do Not Play Compliance Officer.
Sadly, the days of a physician operating a small practice
with a spouse acting as the general administrator have
long been swallowed by the ever-increasing complexity
of compliance. The private physician already wears
many hats (practitioner, business manager, marketer,
human resources director, etc.), and wearing the compli-
ance officer hat is simply one too many. An owning
physician certainly must comprehend and enforce
compliance within the practice, but the amount of time
it takes to keep pace with the fluidity of federal, state,
and payer regulation makes this an impossible task.
Investment in a Certified Medical Compliance Officer
(“CMCO”) or Certified Professional Compliance
Officer (“CPCO”) (generally “CO”) is essential to
setting a physician free to perform at what they do best
– practicing medicine and growing a business. A CO
should be your right hand that ensures your providers
and staff understand all compliance aspects of your
practice, are participating regularly in an active compli-
ance plan for the practice, and are ever-vigilant for
lapses.
3. Create an Active Compliance Plan.
A compliance plan is not the 60-page document you
purchased from your healthcare attorney (or printed
from the Internet) that has been sitting on a shelf in
your break room collecting dust. Time and time again
practices have hung themselves by handing over a stale
compliance plan to an auditor to prove their efforts at
compliance only to discover that the majority of
requirements in the plan have not been followed.
Auditors will use a stale compliance plan as sufficient
“notice” and construe all errors since creation as either
intentional misconduct or severe negligence.
A compliance plan should identify all current provid-
ers and staff in the practice by name, identify their
roles, delineate duties, and encompass all services being
offered in the practice. Yes, the plan should be updated
for every personnel change. Yes, every time the practice
drops or adds a service, the plan should change. Every
provider and staff member should receive quarterly
training, fully comprehend the changes to the compli-
ance plan, and sign a log to document their ongoing
participation.
4. Tracking Records Requests and
EOB Denials.
Besides stopping the misuse of an NPI, tracking records
requests and EOB denials from payers is the second
best weapon for audit prevention. The basic task of
tracking records requests and EOB denials by payer in a
spreadsheet by date, volume, service, and value is one of
the most predictable forecasters of what is coming.
Annually, Medicare starts a charge with the Work Plan,
then the Supplemental Plans and private payers follow
suit. If your practice is performing a service out of
compliance or is an outlier based on the type of service,
the requests and denials will begin to trickle in and
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