Medicare is the country's largest health insurance program. In general it covers individuals over the age of 65 who are not working for an employer that provides insurance coverage, some disabled patients, and individuals with end stage renal disease. All in all nearly 40 million individuals receive at least some of their health insurance through this program. A description of the Medicare program for consumers is at http://www.medicare.gov/basics/overview.asp.
Medicaid is a state run health insurance program for certain low-income and needy people. It covers approximately 36 million individuals including children, the aged, blind, and/or disabled, and people who are eligible to receive federally assisted income maintenance payments. It is financed by both state and federal sources. A description of the Medicaid program for consumers is at http://www.hcfa.gov/medicaid/mcaicnsm.htm.
Spending for both of these programs is large, and increases exceed the rate of inflation. In an endeavor to keep growth at a sustainable rate, one government initiative is to aggressively combat fraud and abuse in health care. Conflict of interest issues and provider billing are undergoing particular scrutiny. When a physician or hospital sends in a bill to a governmental or a private insurer, the health care provider describes what problem the patient had and what services were rendered by using a series of alphanumeric codes. The implied understanding between provider and payer is that the coding is accurate and the services were proper for the patients' level of illness. Routinely when the bill is submitted payment is made, and to a great extent it is an honor system. This arrangement breaks down if the insurance company does not timely pay the approved amount for covered, appropriate services, or if the health care provider engages in fraud or abuse in billing.
There are a few blatantly unscrupulous providers who knowingly bill for fictitious visits or procedures. Obviously these entities need to be shut down and prosecuted. A few providers very aggressively bill for services. This is not fraudulent in the strict definition of the word, however they are abusing the system. The vast majority of health care providers endeavor to submit accurate and appropriate bills and certainly the preponderance of invoices are in this category. When a coding error occurs it is most likely not because of fraud or abuse but due to a legitimate error in a complex coding system. Coding is not always straightforward and sometimes even expert chart abstractors disagree.
It is in the interest of all legitimate health care providers to combat fraud and abuse, and to insure that their billing is accurate and appropriate. In an endeavor to help insure this for our practice Dr. Elliott has set up the following corporate compliance program. If you have any concerns about our policies or a question regarding a specific bill please review the following and contact us. All inquiries will be expeditiously and fairly evaluated. Errors will be corrected.
Dr. Elliott and his staff are committed to the principals as described in the AMA Principles of Medical Ethics. As part of these standards is the requirement physician's respect the law and provide appropriate patient care. An intrinsic part of these values is a commitment to appropriate chart documentation and billing practices. Specifically, up coding, over coding or any other abusive practices will not be tolerated.
Our office has a staff of three employees, and all are committed to this policy. Dr. Elliott as owner of the business has the authority to set the organizational practices, and institute any necessary changes. He is currently designated as the compliance officer. The compliance officer has and will continue to participate in educational activities with respect to ethical medical principles in general, and HCFA fraud and abuse policies in particular.
Claim development submission is the responsibility of Dr. Elliott. This individual will assign the appropriate CPT4 and ICD9 codes. Any returned claims because of coding questions will be reviewed by him and appropriate appeals or corrections made. The following is the standard for our medical records:
All employees are aware of this corporate compliance plan and effective communication is a two way street. If you have a concern contact Dr. Elliott and we will respond. Confidentiality will be maintained, and no retaliation will be tolerated against individuals making a complaint.
If an error in billing is found by virtue of an internal audit or because of a received concern appropriate refunds will be made. A review of similar cases will be done to determine if the event is isolated or more generalized. Any appropriate refunds will be made, and system changes instituted to prevent a recurrence. If Dr. Elliott requires outside help in reaching a decision the Delaware Medical Society Physician's Advocacy Office will be consulted.