The Dartmouth-Hitchcock Medical Center (DHMC) has a successful history of implementing and effectively orchestrating its compliance initiatives. DHMC was the first academic institution that emerged unsullied from the Physicians at Teaching Hospitals (PATH) audit. Due to observance of the guidelines and satisfactory results from auditing claims, the Office of Inspector General (OIG) ultimately dropped the investigation at DHMC with no assessed penalties. However, the investigation resulted in an expense for the institution in excess of $1 million for associated legal counsel, outside audit, and in-house staffing during the audit.
Long before formal corporate compliance programs became part of this industry’s business, DHMC developed a compliance process in response to the Medicaid 1989 investigation at the University of Colorado. “The Colorado investigation created an opportunity for DHMC to learn from the experience of others,” says Thomas Corindia, chief financial officer for the faculty practice at the time of the investigation. Corindia is now the corporate compliance officer (CCO) for DHMC.
Shortly after the Colorado incident, DHMC received feedback from the investigation, sought legal advice, and arranged to meet with the local Medicare carrier for an expanded understanding of the teaching physician rules. In addition to the carrier’s guidance, DHMC also sought information via the Freedom of Information Act and through associated literature available at the time. Once the investigation was perceived as an issue, a higher level of support was organized to carry out the preceding steps. This support consisted of CEO sponsorship, clinic physician leaders, and the directors of the various residency-training programs.
The less formal plan consisted of billing guidelines, clear policy on teaching presence, and a training program for educating physicians. Concurrent to the policy development, DHMC performed a risk assessment on claims to ensure they were compliant with the rules. Associated documentation from the medical record and physician notes was obtained to back up the data reported on the claims. A redistribution of professional coders to the clinical sections, as well as an increase of staff to the coding complement, proved to be an effective move toward streamlining communication and accurate recording of physician involvement. It was this overall approach, the basis of our current program, that characterized DHMC’s pioneering compliance program.
DHMC’S CURRENT PROGRAM ROLES
Today, DHMC’s compliance initiative is institution-wide and supported at many levels. Each level of the program involves key personnel assigned specific tasks.
The senior level of the compliance program consists of a subcommittee to the Board of Trustees. This committee, known as the Audit Committee, is charged with the following responsibilities:
- Approve program
- Review the results of current fiscal year activity, on a semiannual schedule.
- Review the recommended program for the coming fiscal year.
- Report findings to the Board of Trustees.
The executive level of the compliance program consists of senior administration within DHMC. This committee is charged with the following responsibilities:
- Set policy
- Coordinate cross-organizational issues
- Establish priorities
- Initiate disciplinary action.
The operating level of the compliance program is chaired by the CCO, Tom Corindia. The Compliance Committee consists of VP-level administration, clinical leadership, and internal audit and key department compliance officers. This committee is charged with the following responsibilities:
- Recommend DHMC compliance program policy
- Monitor OIG work plan and identify issues
- Proactive review of Medicare policy
- Work directly with the Carrier Advisory Committee
- Manage the program on an institutional level.
The department level of the program is decentralized into individual department/section representation of the program, each with the responsibility to solely manage that department’s compliance program. The key departments are as follows:
- Patient Financial Services, hospital and clinic
- Coding Services
- Clinic Review Services.
The department compliance officers are charged with the following responsibilities:
- Review/audit department policy and procedures
- Micromanage the compliance program as it relates to the department.
- Monitor policy from Medicare
- Implement recommended change with regard to rules and regulations
- Proactively collect/assess data relative to upcoming issues.
The role of a compliance officer is not strictly limited to applying regulations. Compliance programs have a natural effect on quality assurance. There can be no compliance without ethics and no ethics without compliance. It is imperative that while one is consumed with implementing the health plan’s laws and regulations, one should not put aside the primary objective of performing patient care and satisfying patient needs. DHMC remains ready to challenge the Medicare system on protocols and methodology that negatively impact the clinical care of patients. The ideal objective of a compliant system should include appropriate care, billing, and reimbursement, all of which work toward the common goal of providing fair and accessible care for our patients.
One primary way of accomplishing this goal is for an institution to be in a proactive role rather than a reactive role when dealing with Medicare regulations. The Compliance Office of DHMC stresses to its members that they should think outside of the box. The box, which includes the majority of our industry’s compliance programs, caters to a direct role with regard to regulations. This direct role engenders reactive measures to Medicare regulations. Working outside of the box requires a collaborative role between the provider and the fiscal intermediary. In this role, the provider is proactive in reviewing the proposed Medicare guidelines, as outlined in the following graph.
DHMC’S CURRENT PROGRAM
DHMC has created an ethical environment, where the tools and resources are readily available to achieve compliance initiatives and measure their success. Achieving a well-rounded compliance program is not a simple task for any organization. Basic rules, model plans, and a code of ethics are only the beginning of a tedious, self-education process. Many of the policies in DHMC’s program were born out of a series of trial and error processes. Some of the keys to the success of the compliance program are as follows:
- Within the Coding Department for professional services, there are compliance-specific coders, who provide support to the coding staff. In addition, these coders play a key role in provider education on compliance.
- Either a full-time compliance officer or a middle manager with shared responsibilities for compliance represents every significant department within DHMC.
- The Internal Audit Department performs risk assessments, during which it searches into information systems, audits the data, records the results, and provides feedback to all levels of the program.
- Having compliant information systems, which are capable of self-editing claims for inconsistencies, has reduced the errors on claims significantly.
- The requirement of an annual compliance plan from each of the compliance officers and related departments is part of the overall program.
- Maintain involvement with the Carrier Advisory Committee, attend education conferences on compliance, network with members of the educating organizations (for example, Radiology Business Managers Association, American College of Radiology, American Healthcare Radiology Administrators), and hire staff who have a background with third-party billing.
RADIOLOGY DEPARTMENT POLICY
The attending radiologist in an academic setting, where services rendered by the attending involve a resident in the care of the radiologist’s patients, must be identified when submitting the claim on the HCFA-1500 claim form or electronic media claim equivalent. Identifying such an encounter requires the use of the GC modifier. The GC modifier must be reported on the HCFA-1500, and must be entered by the physician for teaching physician services rendered in compliance with all the requirements outlined in section 15016 of the Medicare Carrier Manual. Additional guidelines on teaching physician services for years prior to 1996 can be found in the IL-372 guidelines. Listed in the December 1996 Federal Register are the current guidelines on this subject.
Building a system or mechanism that appropriately identifies the GC modifier is more complicated than simply noting whether or not a resident participated in the service. It should involve linking the modifier to the certifying or attesting documentation in the medical record that indicates the teaching physician was present and performed the necessary requirements for billing. These certifying, or attestation statements, must be the driving factor for the addition of the GC modifier since it is the presence of the statement that determines whether or not the service is billable in the first place.
Most radiology procedures fall into two categories:
A) Films, ultrasound, CT, MRI, and all noninvasive procedures that involve looking at an image and interpreting that image in report format. Medicare will reimburse a physician if the interpretation is performed or reviewed by a physician other than a resident. If the resident prepares and signs the interpretation, the teaching physician must attest that he or she has personally reviewed the image and the resident’s interpretation and either agrees with it or edits the findings prior to report finalization.
B) Invasive procedures that go beyond simply imaging the patient, which are coded with supervision and interpretation (S) codes. In order to bill for surgical, high-risk, or other complex procedures, the teaching physician must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure. This means that the attending radiologist can not have two interventional rooms or two procedures operating during the same time. The same rules apply in the operating room.
DHMC has developed a system that provides the teaching physician with a list of attestation statements to choose from when viewing reports in their queue. The system will not allow teaching physicians to finalize or sign off on the reporting process unless they have selected a statement attesting to their involvement with the procedure. The attested statement will show up as part of the final report. The involvement level, hence the GC modifier for the claim, is determined from the attestation statement chosen by the teaching physician.
In recent years few sectors have been subject to greater federal scrutiny than the health care industry. For the past 3 years, Congress has supported the mission of antifraud legislation by continually authorizing more funding and personnel for investigating allegations of fraud and abuse. In addition, Congress enacted two primary laws, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the Balanced Budget Act (BBA) of 1997. In FY 1997, HIPAA provided the Federal Bureau of Investigation and the Department of Justice with increased funding for a combined amount of $75 million as backing for the investigations.
Compliance — the modern-day buzz-term for acknowledging exposure to fraud and abuse billing rules and regulations — is best addressed in an official capacity through the implementation of a compliance plan or program. There are two types of compliance plans. A federal imposed compliance plan, or corporate integrity agreement, is most likely a requirement after an investigation by government authorities where fraud or abuse has taken place. The suitable alternative is a voluntary compliance plan, which is implemented by the provider to ensure adherence to federal and state regulations, and an action plan to correct any deviation from such. A voluntary compliance plan comprises the following core elements:
- The development and distribution of written standards of conduct, as well as written policies and procedures that promote the hospital’s commitment to compliance (an example is to include adherence to compliance as an element in evaluating managers and employees) and that address specific areas of potential fraud, such as claims development and submission processes, code gaming, and financial relationships with physicians and other health care professionals.
- The designation of a chief compliance officer and other appropriate bodies, such as a corporate compliance committee, charged with the responsibility of operating and monitoring the compliance program, and who report directly to the CEO and the governing body.
- The development and implementation of an ongoing effective education and training program for all affected employees.
- The maintenance of a process, such as a hot line, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistle-blowers from retaliation.
- The development of a system to respond to allegations of improper/illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, and regulations of federal health care program requirements.
- The use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas.
- The investigation and mediation of identified systemic problems and the development of policies addressing the nonemployment or retention of sanctioned individuals.
In 1997, the OIG issued the first of three (to date) compliance program documents. These documents are intended as model plans and are based on the above core elements. It is especially important to remember that practices should not subscribe to the one-size-fits-all idea, when designing a compliance plan. Depending on the practice’s attributes, there are individually important characteristics that each practice/group should take into account. Having a well-designed, monitored, and effective compliance program could ultimately distinguish between an honest mistake versus intentional fraud and abuse in the eyes of a federal auditor/investigator.
David Tupper is radiology finance manager at Dartmouth-Hitchcock Medical Center, Lebanon, NH