In this awareness that delusions no longer serve me, or the greater good, I ask the question, “Am I certain of my alignment with all that integrity with which I claim to be?” I have asked this question of myself recently, personally and professionally, and find that its application and relevance in the realm of compliance is undeniable. After having spent more than 15 years auditing and measuring compliance with regulatory requirements, accreditation standards, Federal and State billing rules and regulations in hospitals, physician practices, billing agencies and laboratories, I am compelled to share my insights.
As an objective observer and auditor whose role it has been to measure the delta that exists between what is, what is expected, and what we, as healthcare providers and administrators believe to be, I have first-hand experience that delusion is rampant in our industry.
And. All too often, we don’t want to look. We don’t want to know the truth. Like so many patients who walk the earth carrying their ills and their diseases without going to a physician until it is too late, delusional of the severity of their prognosis, we fear that knowing the truth may be painful, difficult to treat and expensive to cure … better not to look.
And. We all want to believe that our billing practices are compliant, that the code we have selected is the right one, that the procedure we have coded is billed for correctly with all the proper modifiers and supporting diagnoses. We all want to believe that if the Regulators demand our charts, our documentation, that it will uphold our belief that we are “doing the right thing”, caring for patients and documenting and billing accurately.
Unfortunately, as my experience has proven, rarely are our beliefs proven upon audit. The delta is more often than not, wider than we had anticipated. This is not to say that it is all overbilling either…in as many instances, and in equal measure, we find that providers are leaving monies due them on the table. In either direction, alignment is askew and we do a disservice to ourselves as providers by not collecting properly and to the Medicare program and the American people for payments received in error (too much or too little).
By not looking, the problem persists. The tumor grows. The disease advances in complexity and expense. The delusion serves to enable its perpetuity.
Alas, there is a cure. There is a prevention strategy. There are techniques by which we can become aware of the delta and address it proactively. In doing so, we can further the viability of any provider practice, identify efficiencies in the office, and implement controls to ensure ongoing compliance and right-coding and billing, as the Office of the Inspector General (OIG) has promised through promulgation of compliance program guidance.
Through a compliance program audit, facing the reality of whether we are truly in alignment with the Medicare and Medicaid billing rules and regulations can be the single best “wellness program” or financial risk management program for your practice: awaken to the reality, face the delusion, head on. Initiate a probe sample review of your Medicare claims today.
Here and now, we have the opportunity to cure, to prevent, to be proactive in our attempts to be in integrity with the billing rules. The reality is, PPACA and the Federal Government through Recovery Audit Contractors (RACs) are here to aggressively recoup dollars spent on healthcare errantly to fund the insurance for the un-insured. Defense or offense? Delusion or awareness? Know your delta. Know your compliance rate.
