As we move into the new decade, one of the issues we will be facing in healthcare finance is the reality of additional reviews being conducted by all sorts of entities to ensure that payments are proper.

Of course, we know that with the evolving data-mining technologies that recovery contractors now possess, their ability to identify billing and claims data abnormalities quickly is a real threat to healthcare providers.

As a provider, you also must be concerned if you have a long-standing billing/documentation practice that is inconsistent with accepted and applicable billing/documentation standards (ex: medical necessity). If that is the case, one could argue that you have a "pattern or practice" of billings that could subject you to further reviews, which create the potential for larger paybacks, possibilities of fines and/or penalties, and all of the expense and negative exposure those might entail.

In some instances, it is not beyond the realm of possibility that criminal investigations could ensue if a provider behaves in a manner that shows intent to defraud the government. In summary, if you have improper payments that haven't been fixed, the risk that they will be found is greater than ever!

Block and Tackling

So what is a good strategy for preparing for the RACs in 2010? I would recommend going back to the basic elements of your compliance programs to make sure that your organization is "doing the right thing" to ensure that your payments are proper. Sometimes we lose sight of the basics like the "blocking and tackling" of a football team participating in the playoffs or a big bowl game. The "blocking and tackling" of preparing for the RACs can be done by ensuring that a strong compliance program has been implemented within your organization.

As a reminder, the 1998 hospital Compliance Program Guidance, as recommended by the Department of Health and Human Services Office of Inspector General, lists seven hallmarks of a compliance program:

1.   Designation of a compliance officer and compliance committee;

2.   Development of compliance policies and procedures, including standards of conduct;

3.   Development of open lines of communication;

4.   Appropriate training and education;

5.   Internal monitoring and auditing;

6.   Response to detected deficiencies

7.   Enforcement of disciplinary actions

To assist in determining whether your organization is utilizing its compliance program properly to combat the RAC threat in 2010, let's ask a question regarding each of these elements:

• Compliance Officer and Compliance Committee - how involved are they in RAC preparation and review of corrective actions?

• Compliance Policies and Procedures - do they include the "standard" of refunding overpayments and identifying/correcting the reasons behind the errors?

• Open Lines of Communications - do all staff feel "comfortable" reporting potential overpayments?

• Training and Education - has all appropriate staff received education, on at least an annual basis, regarding why it is important to follow compliant practices and minimize improper payments?

• Internal Monitoring and Auditing - have you performed internal and external reviews of the RAC risk areas? How frequently have they been performed?

• Responding to Deficiencies -- have you made appropriate responses to any identified non-compliant activities?

• Enforcement of Disciplinary Actions - if someone is not following the compliance program or hasn't made the "proper" management decisions regarding identified overpayments, are they being held accountable?

The elements of an effective compliance program can be utilized to prepare for RAC audits and other payment reviews. The ability of an organization to maintain an effective compliance program many times requires its leaders to always "do the right thing."

As 2010 begins, it would be wise to make sure you have an effective compliance program in place that is very involved in RAC preparation efforts.

About the Author

Bret S. Bissey, MBA, FACHE, CHC, is a nationally recognized expert in healthcare compliance. He is the author of the Compliance Officer's Handbook, published in 2006, and has presented at more than 40 regional and national industry conferences/meetings on numerous compliance topics. He has more than 25 years of diversified healthcare management, operations and compliance experience.

Contact the Author:

bbissey@ima-consulting.com