A Preview of the Upcoming
Billing Compliance Plan for Physicians

By: Ronald E. Nyman, Esq.

In December 1998, the U.S. Office of the Inspector General (OIG) of the Department of Health and Human Services issued billing compliance guidelines for third party medical billing services. Upon release of the guidelines, many providers asked the OIG if there were plans for similar guidelines for physicians. The OIG responded that they were not intending to prepare a physicians compliance plan and that providers should look to the billing company compliance plan for guidance. However, it now appears that staff members at the OIG have reconsidered their prior position.

In November 1999, Kimberly Brandt of the OIG informed members of the American Health Lawyers Association that the OIG intends to issue billing compliance guidance for physicians. According to her, the OIG intends to have a working draft ready by March 2000, followed by a comment period. The OIG hopes to have the final rules issued by June 2000.

What can physicians expect in this new compliance program? Many of the elements that are found in other OIG compliance programs, including:

• Implementing written policies and standards of conduct
• Designating a compliance officer and compliance committee
• Conducting effective training and education
• Developing effective lines of communication
• Enforcing standards through well-publicized disciplinary guidelines
• Conducting internal monitoring and auditing
• Responding promptly to detected offenses and developing corrective action

In addition, Brandt explained that the compliance program will cover several risk areas in billing that many physicians encounter.

These areas include:

• Unbundling
• Kickbacks
• Routine waivers of copays and deductibles
• Billing for services not rendered
• Upcoding
• Double billing
• Billing for physician services rendered by non-physicians or teaching physicians
• Medical necessity
• Misrepresentation of diagnoses to justify services
• Completion of certificates of medical necessity for patients not personally and professionally known by the physician
• Billing Medicare or Medicaid for investigation, research, medications and procedures without proper authorizations
• Billing for a non-covered service as if it were covered

Providers should also realize that the guidelines will cover all billing to private carriers as well as to Medicare and Medicaid. Moreover, providers should note that the absence of a plan to date does not excuse them from implementing proper billing and collection procedures. The OIG would most certainly argue that providers should be aware of improper billing practices from their review of Medicare manuals, OIG Fraud Alerts and compliance programs, and other notices.

This article first appeared in the November/December 1999 issue of News Capsule, a publication of The Fairfield County Medical Association.