Recently, we were contacted by the Chief Financial Officer (CFO) of a medical group that provides primary care, urgent care and podiatric care to patients at several locations. The business operates as a corporate practice of medicine. The CFO had no prior healthcare experience. The Chief Operating Officer (COO) also had no prior healthcare experience. They contacted us to discuss their needs with respect to some proactive data analytics and audits; they were informed that there were some billing issues (which is usually the trigger for anything that one would consider “proactive”). Of course, the first thing that comes to mind is how can two people with no prior healthcare knowledge and experience operate a practice like this. The investor, a close family member, did not want to operate the business any longer, and turned it over to these family members.
We immediately sent the call to one of our retired OIG resources to get an understanding of the issues, and where we could facilitate the needs. During the first conversation with the CFO, the question of what CPT codes were at issue was mentioned. The CFO did not know what a CPT code was. As a trained federal agent, our resource immediately saw this as a “clue” that there were going to be greater problems. As the conversation developed, it was learned that there were no real compliance plans in place, no compliance officer, no vetting of any independent contractor agreements, and essentially the business was, well, just running on its own.
We know that most of our readers and connections are in the compliance, auditing and regulatory world, so often times our words fall on ears that understand and sympathize with our frustrations. Fraud, waste, abuse and compliance are real things. Our retired OIG Special Agents recite countless tales of their law enforcement endeavors to clients and potential clients on how the law enforcement (including the criminal, civil and administrative process) system works. We work tirelessly to provide the roadmap for “getting on the correct side,” and yet, we (as I am sure, most of you) still do a head shake when a potential client states that the costs for getting their billing, coding and compliance is too costly. We have blogged about those providers who know they have issues and still wish to take a “wait and see approach” when it comes to an investigation. We tell them they need to stay in the driver seat for as long as possible, and taking the proactive measures to ensure compliant behavior is the main way to stay in that seat. Providers never think that they will be the subject or target of an audit or investigation, until they actually are one. We have often told clients that had they started with proper procedures, analytics and proactive analysis, many of their colleagues would never have met our OIG agent staff.
Providers, are you aware that the Affordable Care Act (ACA), often referred to as "Obamacare," mandates a compliance...