Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

Corporate compliance has been, and will, always be the cornerstone by which a healthcare provider should operate their practice.  It does not matter if the practice is a “mom and pop” shop, or a large, multi-specialty group, with an in-house counsel.  Doing the right thing does not rely upon the size of the organization.  In the particular case of the small or the solo practice scenarios, the ability to ensure a robust and comprehensive compliance program that has some specific metrics for measurement, are often times missing. 

For some time now, I have discussed the importance of proper documentation to support services billed.  I have discussed it in my blog, provided real life examples of cases I worked as an OIG agent, and discussed it in several podcasts (including an upcoming on with Glenn Krauss of Core-CDI).  I will never cease to be astounded at the fact that providers fail miserably in this one area where they have the ability to take control of their own audit and investigative fate.  Feeling that the practice is not budgeted for such compliance measures, did not think to include such measures and other such exculpatory statements do absolutely nothing to absolve the responsibility and liability that will come from a lax compliance regimen.  Self-policing is central to this premise. 

I have stated this numerous times and will continue to espouse this; audits and investigations that have been stymied due to COVID-19 will start up again.  When they do, there will be an onslaught of these reviews, audits and investigations.  Money is bleeding from insurance programs, and I am sure a fair amount is due to fraud, waste, abuse and the general catchall of careless billing, documenting and a poor compliance program.  Simply put, it is not a matter of if a provider will have to pay money back, or if a provider will be caught for fraud, but when.  Three years from now, when the proverbial dust has settled, these reviews will be coming.  It is not a difficult task to implement a program that ensures that codes are submitted to the documentation.

Unfortunately, many providers feel the need to code to the treatment and not to the documentation.  Equally, so many providers will deny that they are coding; yet they all employ a “superbill” in the practice, and circle the codes that are sought for reimbursement.  Circling a code on a “superbill” is coding.  The denial is nothing more than a set of words.  A provider will be held accountable for the false claim, since the provider circled that code.  It is a simple situation; code to the documentation, and do not code to the treatment.  If you document to the treatment, you can code to the treatment.  The circle is complete, and you have conveyed a 360 degree view: treatment is fully documented and code is fully documented. 

My friends in the CDI world will always say that the biggest problem is not over-documenting, but not documenting to the problem and the code that is sought for payment.  Providers can put a lot of works on paper, but if those words do not justify the code billed, the payment will be denied.  A simple proactive measure of conducting internal audits of billing and coding, coupled with some basic data analytics can work to provide a defense against audits and investigations.  Now is the time to being thinking about how to create such a program.  Submitting claims, getting paid, and enjoying the benefits of receiving a low number of denials is not a recipe for complacency.  Providers should always be thinking about where an improvement can be undertaken to ensure that that stream of revenue continues.  Providers do not budget for investigations and audits.  If they did, they would already know their practice has problems.  Practices should budget for compliance, which is vastly different.

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact Eric Rubenstein for more information on our Fraud Spotlight series.