Setting Systems in Place to Prevent Staff from Making Coding and Billing Errors
Louise Lindsey, Editor
Coding or billing errors, the two most common ways which the Medicaid and Medicare programs are defrauded, can take a significant toll on Skilled Nursing Facility administrators in terms of financial penalties or operating license suspension—even if the errors have been made inadvertently. To prevent these errors, or at the very least, reduce their occurrence, a system needs to be set in place and should form part of the overall compliance responsibility of the company.
A billing and coding error prevention system should, at the very minimum, consist of the following elements:
(1) The development and distribution of written standards of conduct, policies, procedures and protocols that address specific areas of potential fraud and abuse. In particular, staff have to be made aware of how errors can creep in the claims development and submission processes. Special focus must also be laid on quality of care issues, and financial arrangements with outside contractors.
(2) The development and implementation of regular, effective education and training programs for all employees, targeted to address their needs based on their responsibilities within the facility. Nurses should be trained in exactness of accounting during rounds, the administration of medicines, and the importance of accurate recordkeeping in general, as unintentional errors in any of these processes can have serious false billing consequences.
(3) Training—or at the very least, written procedure manuals—should be provided to outside contractors to ensure that they too understand the importance of accurate recordkeeping. If necessary, indemnities might also be considered as a last resort legal safeguard.
(4) The creation and maintenance of an effective line of communication between the compliance officer and all employees, including a process, such as a hotline or other reporting system, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation.
(5) The use of audits and/or other risk evaluation techniques to monitor compliance, identify problem areas, and assist in the reduction of identified problems.
(6) The development of policies and procedures which will prevent the employment of persons or outside contractors who have violated corporate or compliance policies and procedures, applicable statutes, regulations, or federal, state, or private pay or healthcare program requirements.
(7) The development of policies and procedures regarding the investigation of problems. This should also include a roadmap on how to develop a prompt and proper response to detected offenses, the initiation of appropriate corrective action, how to handle repayments, and preventive measures.
Having a system in place can also mitigate any punishments which the Office of the Inspector General (OIG) can issue, because, as the Federal Register notice on the matter points out, the OIG “recognizes that the implementation of a compliance program may not entirely eliminate fraud and abuse from the operations of a nursing facility,” but “a sincere effort by the nursing facility to comply with applicable statutes and regulations through the establishment of a compliance program, significantly reduces the risk of unlawful or improper conduct.” The existence of such a program is an indication of the company’s intent in this regard.
