Get Expert Advice on Compliance Safeguards Post-Pandemic

If your practice has been putting compliance concerns on the backburner through the pandemic, be ready, because payers are, cautions Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC, CMPE, CMPM, CPC-P, a partner and vice president of compliance with consulting firm DoctorsManagement and Chief Compliance Officer for the multi-state rheumatology practice Articularis Healthcare Group.

Mr. Weiss

Mr. Weiss says payers are showing increased interest this year in scrutinizing claims, initiating audits and even launching targeted probes, after a reprieve during the COVID-19 pandemic when many audit programs by Medicare and other payers were suspended. “The number of additional documentation requests (ADRs) began to blow like Niagara Falls starting Jan. 1, and it’s only going to intensify throughout 2022 and beyond,” he says.

Medicare’s Comprehensive Error Rate Testing (CERT) program has also been extremely aggressive with new documentation requests. “In some cases, practices’ prepayment reviews are turning into 100% pre-payment reviews—meaning that, prior to processing of a claim, documentation must be submitted by the entity for manual review to ensure medical necessity and that the documentation supports the services billed,” Mr. Weiss says. “This is a painful, laborious process and one that wreaks havoc on the revenue cycle repayment.”

With coding compliance activity up, reimbursements for high-volume, high-expense patient care activities, such as rituximab infusions and concurrent evaluation and management (E/M) services billing for patients under chronic care, are “low-hanging fruit” for both federal and commercial payers to audit right now, he adds.

To help rheumatology practices protect themselves from this new and intense coding scrutiny, Mr. Weiss will be leading a coding compliance bootcamp on April 29, 2022, during the virtual 2022 Coding Training: Best Practices for Rheumatology, part of the ACR Education Exchange. He will cover key aspects of creating a strong and secure compliance program with his “boots-on-the ground perspective” of the trends and latest risk areas for reimbursement investigation he is seeing in rheumatology and other medical practices right now.

“As we are hearing from practices struggling with audits and coding compliance issues, the ACR wanted to provide members with expert insights on current compliance and coding best practices,” says Antanya Chung, ACR director of practice management. “This coding compliance bootcamp with Sean Weiss gives rheumatology practices the wisdom of a veteran compliance officer in an educational format with helpful resources attendees can use now.”

Coding Compliance Bootcamp At-a-Glance

Mr. Weiss says his focus for the bootcamp is to share patterns that can help attendees plan ahead. For example, he’s seeing a current focus on payers scrutinizing billing in cardiology and orthopedic practices for expensive and repetitive services. “From these trends, we can expect payers to be looking at rheumatology practices’ billing for administration of biologics, number and levels of E/M services and prescribing habits.”