For those of you who saw the press release (on Valentine’s Day, incidentally), understand that we are under scrutiny (see “Government Recovers Nearly $4.1 Billion Taken by Fraud,” below). Health care fraud is not something that we, as a profession, can ignore any longer because of reasons such as, “Optometry is small,” or “They don’t pay attention to practices of my size.”
In 1996, when the United States adopted the Health Insurance Portability and Accountability Act (HIPAA), part of the provisions of that were to create and install a compliance officer within your practice. Your compliance officer has many responsibilities, one of which is to insure that your claim submission process for both refractive and medical carriers and your medical records fall within the current guidelines for compliance.
Yet when I ask doctors, “When was the last time you performed a compliance review?” most have a blank look on their face or they answer, “What the heck are you talking about?”
Compliance reviews need to be an essential part of both your offensive and defensive strategies for your practice’s third-party medical claims and medical record keeping.
If you don’t have an idea of what is needed for a compliance review, here are some excellent resources to get you started:
• Compliance Specialists ( http://cseye.biz/) is a firm that analyzes your compliance with Medicare and Office of Inspector General guidelines for CPT code selection, and compares your usage against anticipated usage profiles for medical/legal and audit exposure.1
• “Quality Assessment and Improvement: A Manual for Optometric Practices,” from the American Optometric Association’s Commission on Quality Assessment and Improvement, is an excellent resource on what should be contained in a self-performed compliance review ( www.aoa.org/x5501.xml).
• Your local State Board of Optometry.
• Your individual medical or refractive insurance carrier.
In some practices, medical coding is like a sport: whoever is the most creative or whoever bills the most wins—at least in the short term. But, we shouldn’t be paid for being “creative.” We should be paid for delivering best-of-class care for our patients, and that should always come first.
Government Recovers Nearly $4.1 Billion Taken by Fraud
In February, the government issued a press release that reported its success in recovering billions due to health care fraud: “Health Care Fraud Prevention and Enforcement Efforts Result in Record-Breaking Recoveries Totaling Nearly $4.1 Billion—Largest Sum Ever Recovered in Single Year.”
Here’s an excerpt:
“Attorney General Eric Holder and Department of Health and Human Services (HHS) Secretary Kathleen Sebelius today released a new report showing that the government’s health care fraud prevention and enforcement efforts recovered nearly $4.1 billion in taxpayer dollars in Fiscal Year (FY) 2011. This is the highest annual amount ever recovered from individuals and companies who attempted to defraud seniors and taxpayers or who sought payments to which they were not entitled.”
Source: U.S. Department of Health & Human Services website. Press release. February 14, 2012; Washington, D.C. Available at:
www.hhs.gov/news/press/2012pres/02/20120214a.html. Accessed March 6, 2012.
The bottom line: It’s time for you to take charge of your practice, not hide your head in the sand. If you’re not performing compliance reviews on a regular basis, then you’re at risk, plain and simple.
As optometry becomes a bigger player in the health care field, our risk of audit increases commensurately. So, while being more profitable is good, being safe is better. Be sure you know that not only what you’re doing is correct, but how you’re doing it is proper, as well. So don’t delay: Start your “spring cleaning” now.
Please send your comments to CodingAbstract@gmail.com.
1. Disclaimer: Compliance Specialist, Inc., uses ReimbursementPLUS.com as a tool in their compliance review. I have 100% ownership of ReimbursementPLUS.com.
Clinical Coding Committee:
John Rumpakis, O.D., M.B.A.
Joe DeLoach, O.D.
Rebecca Wartman, O.D.
