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.”
The first education session Mr. Weiss will lead during the bootcamp, Introduction to Compliance, will outline ideal targets for coding compliance now and after the end of the pandemic public health emergency. “Unfortunately, the 1–3% of healthcare practices that engaged in fraudulent billing through the pandemic are part of the reason for this intense scrutiny by payers now.” This is requiring all practices to shore up any gaps or inaccuracies in coding that could open them up to audits, he adds.
The next session, Acts, Laws, Regulations, Statute, will provide the latest coding requirements, compliance regulations, legal changes and other rules dictating how federal and commercial payers are structuring required documentation for reimbursement. Mr. Weiss will also share what he is hearing from Washington, D.C., about trends in fraudulent claim litigation. For example, a recent ruling in the Fifth Circuit Court found that overbilling Medicaid was considered not only fraud, but “aggravated identity theft” with a mandatory minimum two-year prison sentence under a special statute.
After providing a solid understanding on the current rules for coding compliance, Mr. Weiss’ next session, How to Structure Effective Policies, will give individual practices of any size the tools to create coding policies that set them up for compliance success. “The key is to create a culture of compliance in your organization where effective policies and procedures specific to rheumatology are easy to implement,” he says.
His final two education sessions for the bootcamp will give practices more tools for safeguarding correct coding practices with discussion on Developing Internal Controls and Rolling Out Education for Staff. “When it comes to billing, education is essential for every person working in a rheumatology practice, because every element of practice management goes into accurate coding and documentation,” he notes. For example, it’s important that physician notes are accurate and complete and aren’t simply cut and pasted from the patient’s last visit, because such notes are scrutinized during audits.
Who Should Attend
Ideally, Mr. Weiss suggests that representatives from clinical, operational and billing areas in a practice should attend the bootcamp together, so current rules and needed updates can be understood as a team. “I’m excited to take the trends and outcomes of cases we are dealing with to bring relevant solutions to attendees,” he says. “I’m also eager to hear about challenges attendees are facing so we can discuss solutions in real time.”
Mr. Weiss and Ms. Chung will lead Q&A sessions with attendees after each topic discussion during the bootcamp.
“We are eager to connect with attendees during the bootcamp and symposium to share resources for additional support,” Ms. Chung notes. Additionally, Ms. Chung encourages members to participate in the full coding symposium, which will continue after the bootcamp from 3:30–6:00 p.m. EDT. It will provide a deep dive into coding and billing updates, including E/M coding and split/shared visits for 2022 and beyond.
Learn more about this bootcamp and other offerings at the ACR’s 2022 coding and compliance symposium, and explore other ACR resources to support coding compliance.
Carina Stanton is a freelance science journalist based in Denver.
