Avoiding the Hidden Dangers of Compliance

I come to you a day early this week at the beginnings of a vacation.

My one-week break (save for this space) started with an interesting occurrence in my neighborhood. As my family and I were sitting down to dinner last night, we saw flashing lights coming in from our front window. These lights were the beginnings of what turned out to be a gathering of four fire engines, one fire SUV (the chief drives stag), two police cars and – one interesting addition to the vehicular melee – an animal control van. It seems that a house across the street from my own in Milwaukee was discovered to contain a bevy of unattended exotic wild animals, including 5 anacondas ranging in length from 20 to 30 feet.

I am very much a man with concrete in my soul. Due to a contented life of urbanization, annoying allergies and a pathological fear of bugs, I’ve always preferred city life. Say the word “camping” to me and I instantly think of a room on the bottom floor of the hotel. Early yesterday, the list of pluses for city living also included the words “….and no tropical snakes!” at the bottom of it. I guess we can scratch that off now. I used to get a good laugh at the local news’ “man-in-the-street” interviews with stories like this. It’s not so rib-tickling when those sudden TV personalities are your neighbors talking about another person in your neighborhood who decided on his own to start an unsupervised Brazilian zoo in the middle of your block.

Yesterday’s improvised neighborhood reptile round-up was yet another reminder that the world is full of hidden dangers. As my mind races at the thought of what happens the next time I stand in the shower with the water running thanks to my neighbor’s keen interest in herpetology, I also spare a thought to the hidden dangers in the world of medical billing, specifically as it relates to compliance and government audits.

I try to explain it to the laymen in the following fashion: every bit of information that goes out on a typical health claim to an insurance carrier has the potential not only for denial, but for larger compliance problems down the road. Try this exercise: find a blank CMS-1500 form some time and start from Box 1 in the upper left hand corner and work your way down all the way to Box 33b in the lower right. In each box, identify a reason for that box as to why a claim would be denied by an insurance company. Depending on the payer, the reason for the claim, the services being claimed, and a host of other factors, an experienced biller or coder should be able to identify errors that could occur with at least 20 fields that could potentially lead to a claim denial. These could be as simple as “Date of birth entered incorrectly” to “CLIA waiver number not included in Box 23 for a governmental payer”

The compliance view doesn’t stop there. The last question that should be asked before a claim is prepared for billing should always be “Do the services reported on this claim best represent what is documented in the patient’s medical record?”. If there is any question whatsoever of the answer being a firm “Yes!”, It’s best to give the claim a second look.

With some regulatory teeth provided by the Patient Protection and Affordable Care Act, the compliance landscape for providers of all specialties is about to morph into something more intense than we ever could have imagined just 10 years ago. Five years from today, more sets of eyes will be looking at medical claims than ever before, thanks to an alphabet soup of regulatory agencies both currently in existence and still on the drawing board. Now is more than past the time to internalize the idea that the contents of every claim, much like the house full of serpents down the block, is something that should be taken very seriously.