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HOW TO DE-STRESS THEPOLITICS OF PHYSICIAN CODING
Howard Tepper
Vice President for Physician Practices and Ambulatory Services, St. Joseph’s Healthcare System (SJHS)
Regina Gurvich
Chief Compliance Officer, Manhattan’s Physician GroupHCCA 2013, DC
COMMUNICATION & BUY-IN
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PHYSICIAN BUY-IN
Physicians are in a unique position of trust
Determine what services are ordered and billed
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PHYSICIAN BUY-IN
No Compliance Officer Biller Manager CEO
Lost their ability to bill MedicareOnly physicians have itOnly physicians lose it
WHAT WORKS WITH THE PHYSICIANS? You cannot do this alone
Must have senior clinical buy in
Pick the low hanging fruit first
Bring physician success stories with you
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WHAT WORKS WITH THE PHYSICIANS?
Less is more The devil’s in the details Take home book Access to trainer or expert
Why is this important = how can this affect me? Focus training on physician’s unique role
WHAT WORKS WITH THE PHYSICIANS?
Distinguish compliance from other administrative hassles
Do not make compliance the bad guy
Correct coding and compliance does not equal decreased reimbursement
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WHAT WORKS WITH THE PHYSICIANS? Its about getting credit for the work that is done
If you are not part of the solution You are part of the problem
Have ready and implementable solutions
Provide useful advice for private practice
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WHAT WORKS WITH THE PHYSICIANS? Acknowledge their concerns
Do not get into a debate
Do not defend the rationale for the rules Help them comply!!!
WHAT WORKS WITH THE PHYSICIANS?
These are not your rules
Purpose is to assist them
Compliance = Correct Coding = $ $ $
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WHAT WORKS WITH THE PHYSICIANS? Schedule training around their schedules
Early Middle Late
Make location convenient
Serve food
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WHAT WORKS
Don’t react
Don’t take it personally
Don’t be defensive
They are not yelling at you….
They are just yelling
COMMUNICATION AND DIVERSITY
“ Know the man before attempting to do him good." Nathaniel Hawthorne
“ Know the PATIENT before attempting to do him good."
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NOT JUST LANGUAGE
If we all spoke English everything would be fine
50-90percent of communication is non verbal
COMMUNICATION STEPS
Listening, Explaining, Asking, Recommending Negotiating
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PROCESS FOR CREATING MAJOR CHANGE
Establish sense of urgency
Create guiding coalition
Develop a vision and strategy
Communicate the vision
Adapted from “Why Transformation Efforts Fail” by John P. Kotter
PROCESS FOR CREATING MAJOR CHANGE
Empower broad-based action Generate short term wins Consolidate gains and produce more change Anchor new approaches in the culture
Adapted from “Why Transformation Efforts Fail” by John P. Kotter
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WHAT ELSE ARE YOU UP AGAINST?
“We’re not crooks” “We’re too busy” “Billing is not my job” “It’s not fair” “This too will pass” “Nobody ever told me that!”
MESSAGE POWER
This is important Why we think this is
important Why you think this is
important Why you think this is
important to people we care about
► Lower► Low
► Moderate
► Higher
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PRE-COMMUNICATION
If you don't care where you're going
……It doesn't make a difference which path you take
Fix what's broken
Fix what's not broken
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CONFLICT
TYPE OF CONFLICTS
Personal Professional Emotional Personality Litigation Political Geo-political Military….
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“The ability to deal with people is aspurchasable a commodity as sugar or coffee,and I will pay more for that ability than forany other under the sun.”
JOHN D. ROCKEFELLER
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WHAT IS “CONFLICT”?
Organizational conflict is a state of discordcaused by the actual or perceived opposition ofneeds, values, and interests between peopleworking together.
Conflict of Interest can be defined as anysituation in which an individual or corporation(either private or governmental) is in a positionto exploit a professional or official capacity insome way for their personal or corporatebenefit.
WHAT IS “CONFLICT”?
Interpersonal conflict occurs when two or more individuals who must work together fail to share the same views, and have different interests or goals. Interpersonal conflict can be defined by the focus and source of the conflict.
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TYPES OF CONFLICTS
People-Focused vs. Issue-Focused Personal Differences Informational Deficiencies Role Incompatibility Environmental Stress
CAUSES OF CONFLICT
Difference of style Poor communication Different value Differing interests Scarce resources/ budgets Personality clashes Poor performance
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EFFECT OF CONFLICT
Mis-communication resulting from confusion Refusal to cooperate Quality problems Missed deadlines or delays Increased stress Decreased customer satisfaction Distrust Gossip
CONFLICT VS. DISAGREEMENT
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People talk to each other about what they disagree about, and everyone knows who is on which side.
Disagreement is all about content.
Most or all of the participants in the conflict, do not talk to each other.
Feelings and assumptions are so strong that the parties cannot or will hear.
Conflict is all about form.
Disagreement Conflict
NEGATIVE EFFECTS OF ORGANIZATIONALCONFLICTS
Divert time and energy from the main issues
Delay decisions
Create deadlocks
Drive unaggressive committee members to the sidelines
Interfere with listening
Obstruct exploration of more alternatives
Decrease or destroy sensitivity
Cause members to drop out or resign from positions/committees
Arouse anger that disrupts a meeting
Interfere with empathy
Leave losers resentful
Incline underdogs to sabotage
Provoke personal abuse
Cause defensiveness
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CONFLICT REACTION PROFILENUMBERING SCALE: 1 – SELDOM; 2 – SOMETIMES – 3. MOST OF
THE TIME
1.___ I can be swayed to someone else’s point of view.2.___ I shut down people who I disagree with.3.___ I address the issue at hand diplomatically and do not attack the individual.4.___ I think that others try to ‘bully’ their way with me.5.___ I express my thoughts and beliefs tactfully when they differ from those just expressed.6.___ Rather than offer my opinion when I disagree with someone, I keep it to myself.7.___ I listen to other people’s point of view with an open mind.
CONFLICT REACTION PROFILENUMBERING SCALE: 1 – SELDOM; 2 – SOMETIMES – 3. MOST OF
THE TIME
8.___ I let my emotions get the best of me.9.___ I raise my voice to make my point.10.___ I tent to belittle other people when making my point.11.___ I look for ways to negotiate and compromise with others.12.___ I have been told I am too pushy.13.___ I make sure I have my opinion heard in any controversy.14.___ I think conflict in meetings is necessary.15.___ I am the most vocal in meetings when trying to get my point across.
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CONFLICT REACTION PROFILE & YOURSCORE
Scoring:• Add the total score from questions 1, 2, 4, 6, 8,
9, 10, 12, 13, 14, 15• Subtract the sum of the score from questions 3,
5, 7, 11
Your Total: _______
*The Thomas Kilmann Instrument
CONFLICT REACTION PROFILE SCORE
1-4: “Pas ~ You may be such a pushover that you allow difficult
people to walk all over you. You will benefit from learning to stand up for your ideas and opinions in a diplomatic and tactful way.
5-10: “Asser~ You are professionally assertive when dealing with
people, particularly difficult people. Continue to be open to listening to different points of view, and express your ideas and opinions appropriately.
11+: “Aggressive” You may be so combative that people might avoid
interacting with you. You will benefit from learning to listen and express your opinions more effectively.
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DEALING WITH CONFLICT – THOMAS/KILMANNMODEL
CONFLICT RESOLUTION STYLE
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Approach Characteristics Examples of Appropriate Use
Avoiding You don’t want to deal with conflict so you stall or ignore issues.
- When one or more parties need time to clam down or consider a situation.- When issues are of low importance.
Accommodating
You forego your concerns, act selflessly, and simply obey orders.
-You are learning a new skill.- The issue is of low importance.
Compromising You split the difference with the other party toreach a quick agreement
-The decision is a temporary solution.- The issue is of moderate importance.
Competing You want to get your way no matter how it affects the other party.
- Securing a contract for new business- Ensuring compliance- When a quick decision is needed
Collaborating You are concerned with fully satisfying both sides. You work long and hard to find a solution.
- When integrating long term solutions.-When gaining commitment- Building bridges
CULTURE-BASED
Western cultural contexts: Fostering direct communication between
disputants
Non-Western cultural context: Involves third-party mediator
Intercultural context: Mixed approach
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WAYS OF ADDRESSING CONFLICT
Accommodation – surrender one's own needs and wishes to accommodate the other party
Avoidance – avoid or postpone conflict by ignoring it, changing the subject, etc.
Collaboration – work together to find a mutually beneficial solution
Compromise – bring the problem into the open and have the third person present
Disputes will not be discussed & addressed
Misunderstandings are not resolved
.
THE RESULT:
People who disagree, are talking to each other,
People in conflict are not
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STRATEGIES FOR REDUCINGCONFLICT
PROCESS CONFLICTS:
“How much control do I have over this process conflict?”
Identify the root cause of the problem and analyze the improvement opportunity
Talk first to the owner of the process Describe the current problem and get
agreement Suggest a workable solution and action plan Follow-through on the plan and give
recognition to the owner of the process
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ROLE CONFLICTS:
“Exactly how do I perceive my role in relation to others involved in this issue?”
Take responsibility for clarifying your role with others involved.
Be prepared to change your perception of your role.
Show your willingness to be flexible in achieving your organization’s goals.
Stay positive. View any role change in terms of the opportunities it presents.
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INTERPERSONAL CONFLICTS:“How much my personal biases and prejudices affect this relationship?”
Write down three behaviors that you could change in order to reduce the conflict in this relationship.
Commit to following through on these changes for at least three months.
Ask the other person involved how you could defuse the existing conflict. Encourage feedback that might seem brutally honest.
Put yourself in their position. How do you think they view your commitment to reducing conflict in your relationship? Why?
Make a list of 5 strengths that you see in the other person. Then list five ways that improving this relationship would benefit you.
DIRECTION CONFLICTS:
“Am I clear on the direction or vision?”
Clarify the discrepancy so that it can be easily described in neutral words and take action.
Ask permission to address the discrepancy with the other person in a friendly, non-confrontational way and gain agreement.
Use “I” and “we” messages rather than “you” messages.
If there is a difference in values, always go with the higher value.
Make authentic commitments.
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EXTERNAL CONFLICTS
“How much control do I have over this factor?”
Choose to fight battles that are worth the price. Put your energy into things you ‘can do’ rather
than complain about what you ‘can’t do.” Do something good for others. Maintain perspective and a sense of purpose. Talk to someone you trust.
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DEFUSE CONFLICT
DEFUSE CONFLICT
1. Get educated2. Adopt a Zero-Tolerance policy3. Show respect4. Seek to understand both sides of any conflict5. Be solution oriented6. Show willingness to negotiate7. Be willing to be wrong8. Allow people to be different9. Practice good communication skills10. Stay calm11. Ask a neutral third-party to mediate
HOW TO OVERCOME DEADLOCK
o Attack the problem, not the persono Focus on what can be done, not on what can't be
doneo Encourage different points of view and honest
dialogue o Express your feelings in a way that does not blame. o Accept ownership for your part of the problem o Listen to understand the other person's point of
view before giving your own o Show respect for the other person's point of view o Solve the problem while building the relationship
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STAGES OF CONFLICT RESOLUTION
o Focus on the issueo Meet on neutral groundo Stick to the factso Listeno Work for a win-wino Follow through and follow upo Be ready
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COMMUNICATION MODEL
POWER
Sender Receiver
MESSAGE
FEEDBACK
ENVIRONMENT
PRINCIPLES OF FEEDBACK
Information about past behavior, delivered in the present, which is intended to improve future work relationship.
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PRINCIPLES OF FEEDBACK
o It allows us to build, maintain, or test our relationships
o It is the best source of information
o It is a “reality check” of our perceptions, reactions, observations, or intentions
o It allows the recipient to identify and reinforce his/her positive contributions and to identify and change behaviors that are not helpful
FEEDBACK PROCEDURE
THINK…………………….A.I.D.
A = Action Tell the person what s/he said/did
I = Impact Let the person know how it affected you or the work
D = Desired change in behavior Tell the person how
s/he can improve the situation
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MOCK
CONFLICT RESOLUTION
WHO HAS NEVER EXPERIENCEDCONFLICT OF ANY KIND?
WHAT DOES NOT WORK?
WHAT HAS WORKED FOR ANY OFYOU?
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BUILDING THE BRIDGES WITHPHYSICIANS
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INTERACTING WITH PHYSICIANS
General characteristics - Usually competitive in nature
Like to be the best or a leader in their field Compete with their peers as well as themselves
High school to college College to medical school Medical school to residency and fellowship Residency and fellowship to private or academic practice
Like challenges Desire perfection Want to be correct
INTERACTING WITH PHYSICIANS
General characteristics
o Interested in processes thato Improve quality of patient careo Improve productivityo Improve patient satisfactiono Improve efficiencyo Improve reimbursement and cut cost
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INTERACTING WITH PHYSICIANS
General characteristics Education
Highly educated in their field and/or specialty
Usually interested in advancing their understanding of the healthcare industry Specifically interested in understanding
outside factors that may impact them Personality
All walks of life but share common traits such as: Want to do the right thing Analytical thinkers Usually collaborative Research, science and fact based oriented Entrepreneurial
INTERACTING WITH PHYSICIANS
Capitalize on their general characteristics Competitive by nature
Provide data when discussing compliance concerns that compare them to their peers, locally, regionally, and nationally, if possible
Be mindful of their time Just the facts
Pointers – Building Bridges
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INTERACTING WITH PHYSICIANS
Generally, don’t start off conversations with
In accordance with the law you must .... The OIG said…. CMS Billing Manual citation…. Penalties under the False Claim Act are….
Pitfalls – Instant Bridge Burners
BUILDING PHYSICIAN - COMPLIANCE
OFFICE RELATIONSHIPS
Politics Get buy-in from the top
Learn the landscape and develop your Physician Champions
Implement a program with your Physician Champions that works for your organization
Remember these Physician Champions are your greatest advocates to facilitate delivery of your compliance message to the medical staff throughout your organization
Pointers
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INTERACTING WITH PHYSICIANS
While these are great ways for Compliance Professionals to discuss compliance issues, physicians may be thinking Here we go again, non physicians telling me how to practice
medicine This person doesn’t care about the patient Great, more work for me to do because some clipboard-
carrying administrator or blue-suit behind a desk feels my job isn’t difficult enough already
Who are you in Compliance to tell me how to run my practice
Pitfalls – Instant Bridge Burners
BUILDING PHYSICIAN - COMPLIANCE
OFFICE RELATIONSHIPS
Politics Developing physician champions
Who, what, where, when, why and how
Theory to implementation
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UTILIZING AND LEVERAGING
RELATIONSHIPS WITH YOUR PHYSICIAN
CHAMPIONS
How can the Compliance Office help the Physician Champions? These Physician Champions will receive
questions from their peers so it is critical that they understand some basic high level compliance issues
Macro level – be their advisor Physician Champions will need assistance
from the Compliance Office
BUILDING PHYSICIAN - COMPLIANCE
OFFICE RELATIONSHIPS
Politics do play a role You need buy-in from the top
CEO, CFO, COO These individuals have a significant, vested interest in
compliance. It is these individuals with whom you discuss increased efficiency, decreased risk of penalties, fines, and so forth
If these individuals are on board with the compliance program, it should make it easier to get physician buy-in and involvement
These individuals may be able to help encourage physician interaction with the Compliance Office
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BUILDING PHYSICIAN - COMPLIANCE
OFFICE RELATIONSHIPS
Buy-in is critical Have to understand your corporate culture to
select and develop your Physician Champions
Build something that works for your organization
Be sure to communicate and monitor the compliance message being delivered by your Physician Champions
Summary
BUILDING PHYSICIAN - COMPLIANCE
OFFICE RELATIONSHIPS
What will the Physician Champions do once the relationship is developed?
They are eyes and ears among their physician colleagues Report on areas of concern from a physician’s point of
view They serve as advocates for the Compliance Office
They may be the ones to carry the “compliance torch” among their peers
Most importantly, they are your liaison between the medical staff and the Compliance Office and can be instrumental in advocating for change within an organization
Assist with breaking down the us vs. them mentality Encourage reporting of violations and suspected
violations Influence physician participation in educational
programs
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BUILDING PHYSICIAN - COMPLIANCE
OFFICE RELATIONSHIPS
Politics Buy-in can not come by compromising on ethics or
integrity Result in less than favorable participation from your
Physician Champions Devalue your program and set you up for failure
Failure to know your audience is a disaster waiting to happen
Not all models work for every organization
Monitor the compliance message your Physician Champions are communicating to the medical staff
Pitfalls
UTILIZING AND LEVERAGING
RELATIONSHIPS WITH YOUR PHYSICIAN
CHAMPIONS
Be the Physician Champions’ advisor on macro level issues Major changes or proposed major changes that will
impact their area or the entire organization
Be the Physician Champions’ consultant on micro level issues Know their specialty and issues that impact their area Be their consultant for complex compliance issues
Involve the Physician Champions in education as often as possible when conducting training sessions with their peers
Pointers
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WHAT YOU NEED TO KNOW ORINTERACTING WITH PHYSICIANS
INTERACTING WITH PHYSICIANS
Know your audience Know their focus Know their compliance risk Know their characteristics
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INTERACTING WITH PHYSICIANS
Know your audience What is their main focus?
Patient Care and patient safety What is their compliance risk?
Documentation problems Billing for services
Not Documented Poorly Documented
Up-coding and/or down-coding Risk management issues Incorrect reimbursement issues Increased cost to correct mistakes
INTERACTING WITH PHYSICIANS
Capitalize on their general characteristics Appeal to their interests
Demonstrate how documentation can Improve the quality of care and decrease safety
risks Improve overall productivity and efficiency Improve patient satisfaction Improve reimbursement and cut cost
Pointers – Building Bridges
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INTERACTING WITH PHYSICIANS
Capitalize on their general characteristics Education
Provide examples relative to their specialty Provide data from their specialty organization Explain how this helps them to be in the top of their
profession and how compliance impacts their specialty Personality
Ask for their input on how to better improve compliance
Provide facts about what needs to be improved and why Explain why this is the right thing to do
Pointers – Building Bridges
INTERACTING WITH PHYSICIANS
Conversation starters Dr. X, the Compliance Office has identified an
opportunity you can use to Improve patient care and patient satisfaction Reduce risk to patient safety Ensure your documentation can be utilized more
efficiently by yourself and other practitioners Ensure your documentation reflects the excellent
care you provide to your patients
Pointers-Building Bridges
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INTERACTING WITH PHYSICIANS
Appeal to their interests to improve patient care
Appeal to their competitive nature
Understand how to phrase and tailor your discussions and educational efforts with physicians so that each encounter is as effective and efficient as possible
Remember, the goal of most physicians is “the patient comes first” so try to work compliance into their daily patient care routine
Above all, most physicians want to do the right thing!!!!
Summary
BUILDING PHYSICIAN - COMPLIANCE
OFFICE RELATIONSHIPS
Develop your Physician Champions Where to start?
Respected physicians you know may be sympathetic to the goals and objectives of the Compliance Office
Grass roots approach Which physicians are already involved in
compliance-related areas Risk management Quality measures Patient safety CMO and COS Accreditation and Joint Commission Physicians with prior experience of an OIG
investigation or a CIA Other
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UTILIZING AND LEVERAGINGRELATIONSHIPS WITH YOURPHYSICIAN CHAMPIONS
UTILIZING AND LEVERAGING RELATIONSHIPS
WITH YOUR PHYSICIAN CHAMPIONS
How can the Compliance Office help the Physician Champions?
Physician champions will need assistance from the Compliance Office Understand the Compliance Program Plan
Why we have one in place and how it impacts the daily lives of their physician colleagues
Conflict of interest Fraud and abuse laws (Anti-kickback, False
Claims, and Stark)
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How can the Compliance Office help the Physician Champions?
Physician Champions will need assistance from the Compliance Office Major changes within CMS (FI and Carrier change to
MAC, PSC to ZPIC, RACs and MICs) Understanding the acronyms, alone, may be overwhelming!!! Major proposals such as the elimination consultation codes
and how this will impact their organization and practice
UTILIZING AND LEVERAGING RELATIONSHIPS
WITH YOUR PHYSICIAN CHAMPIONS
UTILIZING AND LEVERAGING RELATIONSHIPS
WITH YOUR PHYSICIAN CHAMPIONS
How can the Compliance Office help the Physician Champions?
Macro level – be their advisor Assist with annual compliance training
Helps with both clinical and non-clinical staff to see that the Compliance Office is utilizing physicians to assist and provide guidance with training
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Micro level – be their consultant Individual physician audits
Utilize your Physician Champions to help explain audit findings Less intimidating for the audited physician Helps transform the audit into a collaborative approach to
address the findings, mitigate the risks, and improve patient care
Specialty compliance training Training is provided by someone in the specialty practice
Peer to peer training Provide real-world insightful examples and commentary
on why compliance is necessary within the specialty
UTILIZING AND LEVERAGING RELATIONSHIPSWITH YOUR PHYSICIAN CHAMPIONS
Micro level – be their consultant Billing, coding, documentation and operational
issues The Physician Champions encounter the same issues all
physician’s encounter so they can provide assistance with resolving these issues as they arise
Leverage their “referral” behavior and training The Physician Champions can “refer” their peers to the
Compliance Office to assist with questions or concerns
UTILIZING AND LEVERAGING RELATIONSHIPSWITH YOUR PHYSICIAN CHAMPIONS
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UTILIZING AND LEVERAGING RELATIONSHIPS
WITH YOUR PHYSICIAN CHAMPIONS
Capitalize on how this approach can mold and shape your culture
Leverage this relationship to network, engage, and build relationships with other physicians
Utilize the Physician Champions to make the Compliance Office more approachable
Utilize the Physician Champions to break down barriers and silos
Pointers
Don’t overload or overwork your Physician Champions
Don’t leave them on their own without your support-they need it
Your Physician Champions expect you to be the compliance expert they can turn to for help Give them the same level of expertise and
perfection that you expect of them
Pitfalls
UTILIZING AND LEVERAGING RELATIONSHIPSWITH YOUR PHYSICIAN CHAMPIONS
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POINTERS AND PITFALLS IN GAINING
PHYSICIAN BUY-IN TO A COMPLIANCE
PROGRAM
Interacting with physicians The ability to understand their focus and avenues
to relate or communicate is critical.
Building physician - compliance office relationships This is critical for the success of your Physician
Champions program as well as for the overall success of your compliance program
Conclusions
POINTERS AND PITFALLS IN GAINING
PHYSICIAN BUY-IN TO A COMPLIANCE
PROGRAM
Utilizing and leveraging relationships developed with your Physician Champions Tie everything together you have learned from
interacting with physicians and building your Physician Champions program to help mold and shape your entire organizational approach to compliance.
Leverage these relationships to integrate compliance into their daily routine
Utilize these relationships to network and continue your “Compliance Grass Roots” movement
Conclusions
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A FEW THOUGHTS ONCOMPLIANCE PROGRAM
TRUE OR FALSE
1. Compliance risk does not apply to your practice2. You are too small to be flagged for external audit3. Buying compliance program ‘off the shelf’ will suffice4. Skill sets of billers, coders, compliance, and audit are
interchangeable & replaceable5. 1995 and 1997 Guidelines are about fashion statement6. Incident to = Shared = Split Services7. NPP services do not require MD presence, as long as
NPP has current license8. Locum tenens = Reciprocal = Per Diem9. Self-disclosure and repayment increase compliance risk10. PATH rules do not apply to private practice
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THE AUDIT PROCESS
“The process of audit should be relevant, objective, quantified, repeatable, and able to
effect appropriate change.”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1837310/
COMPLIANCE PROGRAM ON A SHOE STRING
Compliance Confetti Does size matter? What must be there? How many policies is enough? How often does it need to be reviewed?
Organizational Chart Governance Job description(s) and reporting
Audit Documentation Records retention policy Standardization of the processes
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INSOURCING VS. OUTSOURCING
Scope of outsourced function(s) CO, hotline, credentialing, vs. individual audits
Considerations Financial constraints Staffing vs. skill set available Space constraints or availability
Local vs. ‘Long-distance’ contractual relationships
Contracting ‘Know thy consultant’ or vendor selection process Contracting under ‘privilege’ Periodic ‘refreshing’ of auditors pool
TRAINING & EDUCATION
Staff vs. leadership education Formal vs. informal modes Cost-conscientious approach
Webinars Printed materials Periodic e-Newsletters
Investing in line staff education & skill set
Needs to be ongoing and practice focused!
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SCREENING
Credentialing & re-credentialing Compliance program as condition of Medicare and
Medicaid enrollment (coming soon)
Physicians, Staff, and vendors Initial vs. periodic Exclusions Ramifications of failure
Patients Identity verification
Screening for COI, Stark & Anti-Kickback Processes, documentation
LEGAL COUNSEL: OVERSEER OR PEER
Tangled relationship When to involve Legal Counsel?
Trouble shooting Mandatory Reporting of Adverse Events Governance Quality of Care External reviews
Analyzing obligations and timeframes post-internal review
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COMPLIANCE: FROM COST-CENTER TOREVENUE CENTER
Benchmark Assessment & Gap analysis Physician buy-in
Connecting the dots of revenue cycle & compliance Ongoing conversation
Risk Assessment Denial report data as vulnerability Documentation standards Patient satisfaction Approved RAC Review areas
MEASURING SUCCESS
How effective are you? Are you asking the right questions? Are you documenting these questions? Are you sought after subject matter expert within
organization? Do you step outside of your comfort zone?
Internal scorecard for Compliance Feedback from external audits (RACs, MICs, ZPICs,
et al.) Number/ amounts of re-payments Transparency as an organizational culture
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CASE STUDY #1 You are a CO at large IPA, which recently implemented
EMR. As part of the annual compliance work plan you initiated documentation, coding, and billing review.
IPA retains consultant to help you perform this review on-site. The consultant is evaluating a random sample of 50 claims on a pre-bill (Prospective) basis. The consultant starts review and by day 2 requests a meeting with you. During the meeting, the consultant relates that based on review of the first 30 records, 100% of the records included an automatic script/ auto-text of the time for nurse visits indicating that the service was performed incident-to a physician. Also noted were evaluation and management codes of 99214 and 99215 only.
This project is not performed under attorney-client privilege
CASE STUDY #1: CONSIDERATIONS
Where should you start? Since review is done on pre-billing basis, is
overpayment of concern? How was the sampling conducted? (one location/ MD
or IPA-wide) You know obligations to Medicare and Medicaid, but
how should you treat other payers and self-pay? How do you communicate these findings? What does your audit file need to contain? What other remedial actions should be initiated? What other follow-up audits need to be conducted, if
any?
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Comments?
Questions?
Self-Disclosures?
CONTACTS
Howard Tepper, Vice President, Physician Practice and Ambulatory Service at St. Joseph's Healthcare SystemPhone: 973.754.2008Email: [email protected]
Regina Gurvich, Chief Compliance Officer, Manhattan’s Physician GroupPhone: 201-539-2773Email: [email protected]
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REFERENCES
“Workplace Conflict”, Boston University FSAO “Resolving Workplace Conflict”, University of
Colorado-Boulder http://www.dalecarnegie.com Thomas-Kilmann Conflict Mode Instrument