Compliance Resources

Other compliance resources are available throughout the resource section of the site; but these seemed to be best at home here.

Medicare Audits

Today's current hot topic:  Audits! 

Medicare's claim review programs include: MR, NCCI Edits, MUEs, CERT, and RAC.  To understand more about each process, review Medicare's booklet explaining each.

For a current list of  CMS approved audit issues, visit Connolly's website.  

As part of your practice's compliance plan, it's a good idea to include occassional chart audits by an outside reviewer.  Although KLA trains its clients office administrators on how to audit a chart, an annual review from a completely independent third party is favorably viewed should you face an audit by Medicare, Medicaid or another third party payor.  Reasonably priced independent audits are available from:

American Academy of Professional Coders - Audit Services Division - Typically 10 to 20 charts per provider will be provided.  Per its website, the AAPC will provide:  

Our audit team will contact you for a discussion of our findings, as well as send you a written report. Our report will include many key metrics, such as error rates, overutilization patterns, and the financial impact of errors found. We’ll also give you customized documentation tips and improvement recommendations based on our findings.

The cost to review 10 records is $400.  Discounts are often available.

Shelley Garrett(mycodinginstructor [at] yahoo [dot] com), CPC, CEC, CMC, CMOM - Shelley has more than 15 years of healthcare experience. Her experience includes working directly for the Medicare program, in multi-specialty physician offices and hospital settings, and also serving as a compliance officer and consultant.  Shelley is based in Tennessee but is willling to travel and do long-distance chart reviews. 

State Volunteer Mutual Insurance Company - SVMIC, a leading provider of medical malpractice insurance in the MidSouth, is more than an insurance company.  It offers a wide variety of services, many free to its policyholders.  Other services are fee based.  One of the services offfered is a risk evaluation service which includes chart audits.  Call SVMIC at (800) 342-2239 or complete the online form on its website.

OIG's Podcasts For Physicians

Overwhelmed with all the compliance material?  Just plain tired of reading?

The OIG has made it a little easier for the TV/YouTube/IPad generations by addressing some of the more complicated compliance issues with podcasts.

The list keeps growing but some of our favorites include:  Compliance Program Basics, Tips for Implementing an Effective Compliance Program and Importance of Documentation.

OIG's Roadmap for New Physicians

The OIG has issued a Roadmap for New Physicians, Avoiding Medicare and Medicaid Fraud and Abuse on its website.  The tool is well named.  It describes what is and is not allowed between a physician and other parties.  There is also guidance on compliance plans.

The OIG also offers Compliance Program Guidance for Individual and Small Group Practices.  Your practice should have one of these in place AND follow its rules.  At the minimum your compliance program should require your office to:

(from the OIG website)

  • Conduct internal monitoring and auditing.
  • Implement compliance and practice standards.
  • Designate a compliance officer or contact.
  • Conduct appropriate training and education.
  • Respond appropriately to detected offenses and develop corrective action.
  • Develop open lines of communication with employees.
  • Enforce disciplinary standards through well-publicized guidelines

The Patient Protection and Affordable Care Act of 2010 each practice is required to maintain a compliance plan.

Pain Management

To prescribe or not to prescribe pain medication, that's the question.

The answer is easier with a late stage cancer patient than with a patient complaining of an old injury or soft tissue pain.  How do you know if the patient is in need?

Many states have prescription drug monitoring programs (PDMP) that will allow you to check a patient's prescription history.  Printing out such a history and including in a patient's file may prove beneficial in certain cases.

Per the DEA, as of July 2010, 34 states have operational PDMPs that have the capacity to receive and distribute controlled substance prescription information to authorized users. States with operational programs include:

Alabama, Arizona, California, Colorado, Connecticut, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Nevada, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, and Wyoming.

Seven states (Alaska, Florida, Kansas, New Jersey, Oregon, South Dakota and Wisconsin) and one U.S. territory (Guam) have enacted legislation to establish a PDMP, but are not fully operational.

For more information including contact information for your state, visit the National Alliance for Model State Drug Laws

Red Flag Rules

Although Red Flag Rules are not required for medical offices, adopting some measure to protect your patients from identity theft remains a good practice.   Despite not being defined as a "creditor" by federal statute, medical providers may still be held liable for lack of exercising reasonable care in protecting their patients identity.  Thus, it remains good practice to have written policies in place to identify and prevent "red flags," indicators of identity theft.  Staff must be trained and prevention policies implemented.

AMA's Template - American Medical Association's Template for Red Flag Rules.  If members login, they can access an easily modifiable version of the template.  Others most be satisfied with a PDF version.  Still, a great resource for medical offices.

FTC's Template - An online template provided by the Federal Trade Commission to help low risk businesses create a do-it-yourself compliance program. 

Recent Blog Posts
Jan 11, 2021

With many of us doing virtual visits and avoiding social gatherings because of COVID, you may have ...

Jun 14, 2018

On June 14 the Centers for Medicare & Medicaid Services (CMS) updated its Quality Payment ...

May 10, 2018

Sometimes CMS headlines surprise me.  Take for example this one from May 17:

Recent Tweets