Keeping compliant can help avoid unpleasant tangles with CMS

Learning from your mistakes and fixing them is a given in life. But in the world of healthcare compliance, spotting and more proactively addressing mistakes can make all the difference between a routine review and a never-ending audit from hell. 

Joette Derricks, MPA, FACMPE, CPC, AAPC-Fellow, CHC, CLSSGB, chief executive officer, Derricks Consulting, recently spoke to MGMA Sr. Editor Daniel Williams on the MGMA Insights podcast to discuss effective and proactive strategies for dealing with Medicare and Medicaid compliance issues.

Targeted Probe and Educate program

Derricks is an expert on CMS’ new review process, the Targeted Probe and Educate (TPE) program, which was established to work with providers on identifying and correcting Medicare claim errors in order to limit high denials and appeals. Having spent significant time providing expert testimony at court hearings on billing fraud, Derricks suggests providers pay more attention to the potential downside of CMS audits.

“CMS started these targeted probes program a few years back, supposedly with an emphasis on the educational aspect,” she explained. “The program goes through the possibility of pre-targeted probe reviews that are prepaid reviews. They look at the services and say, ‘No, you selected the wrong code here, your documentation doesn’t support whatever the issue is.’ They’re supposed to be an educational session with the provider group or the practice hospital, so that when they look the next time, you’ve learned what the correct rules are.”

Emphasize education ... or else

While CMS designed the program to provide an educational way for practices to avoid making the same mistakes, Derricks said that in reality, the system often does not quite work as planned — or that healthcare organizations seem to routinely underestimate the urgency of the probes.

“The problem that we and other administrators and consultants are starting to see is that the education is not as emphasized as it should be,” she said. “It’s not well-coordinated with the Medicare administrator or the office contractor. (Some) physicians also think this is just a nice thing the CMS is doing for certain multifaceted practices — it’s pre-audit and we don’t have to pay any money back. But they’re missing the fact that this is an audit. If you don’t get the right education and rework your operations, your workflow, your documentation and the EMR templates, you could end up with a very significant payback when it is all over and done with.”

Take a proactive approach

Derricks said the most important step compliance officers or administrators can take to avoid the risk of a targeted probe is to stay on top of their own information at all times, even when analyzing what seem to be routine operations. 

“The number one thing they can do is to be proactive when reviewing and analyzing their own information, their own data,” she said. “Individuals kind of get in a rut in compliance when, every year, they look at the same things and they haven’t gotten any changes. You need to look at things and slice and dice them a lot of different ways. You need to look at frequency changes and reimbursement charges, and are you doing something new or different this year?”

Further, if a range of corrections are offered to a Medicare Administrative Contractor by the TPE, Derricks said it is imperative that companies change their processes as soon as possible. 

“I don’t think there’s enough emphasis put on a corrective action plan and making sure the corrective action is actually taken,” she said. “I think sometimes compliance officers focus on telling the doctors or the coders the rules, but they don’t take the step of making sure that the right tools and processes are in place to see it is being done.” 

'From the get-go'

As a consultant, Derricks said she spends considerable time working with healthcare providers to make sure that the well-intentioned ideas they have for improving their businesses come together with compliance in mind.

“I do a lot of revenue integrity issues, which involve (a provider) building something correctly,” she said. “I work with a lot of hospitals and physician groups in setting up new service lines, and I think it’s really important to make sure that you set up things correctly from the get-go. Too often, a CFO or a doctor goes off to a conference where they hear about this good idea and they come back and say they want to do it, but they haven’t done the right amount of due diligence.”