Strategies to Improve Physician Compliance with Billing and Documentation Rules

Does your organization need to improve physician performance in following documentation and billing rules? If you have faced this issue, consider the strategies developed by the Office of Compliance and Corporate Integrity (OCCI) at Vanderbilt University Medical Center (VUMC), described in the July/August 2011 issue of the Journal of Health Care Compliance. The article, “Challenges and Helpful Hints for Turning Low Performers into Compliant Performers,” was written by Robert H. Ossoff, DMD, MD, CHC, assistant vice-chancellor for compliance and corporate integrity, Darija Giniunaite, CPC, OCCI compliance consultant; and Julie Appleton, CCS-P, CPC, CPC-H, FCS, PCS, OCCI manager.

Physicians and other health care providers (physicians/providers) differ in their experience and knowledge of the applicable documentation and billing rules as well as their willingness to engage in and embrace educational programs related to these topics, according to the authors. As a result of this unpredictable behavior and participation in educational programs, the VUMC compliance officer (CO) and members of the VUMC Office of Compliance and Corporate Integrity (OCCI) team developed successful strategies to train their physicians/providers and transform them into more compliant ones.

The key elements of the VUMC strategy to improve physician/provider compliance outlined by the authors are:

  • Compliance program. The first and foremost element necessary is a strong compliance program, which includes written policies and procedures regarding provider education, monitoring, and consequences of noncompliance. These policies should be applied and enforced consistently.
  • Introductory training sessions. Introductory training sessions for physicians/providers conducted early in their employment. Among the areas of concern addressed are: government and private payer reimbursement principles, proper confirmation of diagnoses, alterations to the medical records, proper documentation of services rendered, and internal policies. The OCCI team provides information about the role of the CO and how the OCCI team assists physicians/providers.
  • Opportunity to attend other educational sessions. Physicians/providers that are not able to attend the main session are required to register for educational sessions provided twice a month at the compliance office website. As an incentive to participate, physicians/providers receive continuing medical education (CME) credits for attending these sessions and are asked to provide feedback after attending the sessions.
  • Auditing and monitoring. After the initial educational session is completed, to promote and ensure compliance, VUMC conducts audits performed by auditors with expertise in federal and state health care laws, regulations, and statutes. VUMC refers to these auditors as “compliance consultants” to avoid the negative connotation of the term “auditor.”
    • The audit is conducted after a physician/provider sees 30 to 60 patients in the outpatient clinic. Each physician/provider audit covers 12 randomly chosen patient encounters.
    • During the personal audit review meeting, the “compliance consultant” further educates the physician/provider, covering extensive details of billing and documentation pertinent to the physician/provider’s specialty. Sufficient time is allotted for the physician/provider to ask questions.
  • Communicating with physicians. In addition to having extensive knowledge of billing and coding rules and regulations, it is essential for an auditor (“compliance consultant”) to have excellent communication skills.
    • During all compliance education sessions, the “compliance consultant” must maintain an engaging, positive attitude, be helpful and supportive, and avoid any type of confrontation with the physician or other billing provider.
    • Compliance consultants should begin audit reviews by highlighting areas that physicians/providers are addressing properly and encouraging physician/providers to continue their good practices prior to sharing the opportunities for improvement discovered.
  • Follow up audit. Within 30 to 60 days, conduct a follow up audit to ensure improvement has been made. If the physician or other billing provider fails to achieve the standards required by the organization’s policies and procedures, proceed with noncompliance actions.
  • Actions taken for noncompliance. VUMC’s audit policy provides for a total of “three strikes” for physicians/providers. Physicians/providers who are not in compliance have a total of three months to improve.
    • During this time, 100% of their bills are reviewed to ensure that documentation and billing is correct. This 100% monitoring is terminated after the provider reaches 95% accuracy.
    • Each physician/provider is charged a progressively increasing monetary fee for each month of noncompliance.
    • If three months of monitoring does not yield improvement, a written action plan must be submitted by the physician/provider and his or her department chair detailing the circumstances surrounding the physician/provider’s failure to achieve 95% accuracy with their billing or maintaining timely completion of the medical record documentation in accordance with policies and procedures.
  • Feedback from faculty.Following the completion of each audit review, physicians/providers are asked to fill out an audit review questionnaire that asks for their ideas on how the monitoring system could be improved to benefit physicians/providers more effectively.

According to the authors, having an effective compliance program that assists low-performing physicians/providers turn into high performers is an ongoing process that requires a substantial commitment of time, energy, resources, and ability to constantly change and adapt to the ever changing health care landscape.

How effective is your organization’s compliance program in improving physician/provider performance?