Auditing When There Are Conflicts of Interest

Healthcare environments are prone to conflicts of interest. Healthcare is the perfect example of a complex adaptive system (CAS).These systems are prone to error on a regular basis, but, lucky for us, they’re also capable of incredible innovation, if the right conditions are created.

Within healthcare, misunderstandings and conflict usually involve several distinct parties, and occur at multiple levels at the same time. It’s critical to define these potential conflicts, especially in relation to oversight in coding, billing, auditing, and compliance, so you can develop strategies for prevention and management.

Conflicts Of Interest: The 3 Most Common Areas

1. Chief Complaint: The chief complaint (CC), as most of you know, is the medically necessary reason for a patient’s visit, captured by the physician. Without a CC, the service should be considered a preventive service. Discussions between providers, coders, and auditors can help resolve differences related to this item.

2. Electronic Health Record (EHR): The advent of the EHR has provided great advances in health information sharing, greater practical patient care, consistency in documentation practices, and increased productivity among providers. However, the technology is not without the prospect of difficult outcomes as well, including capabilities to clone information, improperly designed templates for specialty services, privacy issues, and lack of interoperability between other technologies. Without proper training, maintenance, and oversight of the technology there are sure to be conflicts between staff members.

3. Medical Necessity versus Medical Decision Making (MDM): Medicare provides very specific information regarding medical necessity throughout online manuals, national coverage determinations (NCDs), and local coverage determinations (LCDs). However, the way providers may have received guidance from their medical specialty society may not coincide with Medicare or other payer criteria. If a radiology specialty society designates standards of care for chest x-rays should occur in all patients beginning at age 45 as a preventative measure for possible disease process, this type of diagnostic measure would be inappropriate to bill to Medicare or the Medicare patient in absence of appropriate signs and symptoms. Even the screening tests which Medicare provides coverage for have age and frequency limitations which are important to know in order to properly bill and receive reimbursement.

Education is vital to effectively prevent and manage conflicts. Organizations are much less likely to have internal conflicts when they invest in the education and training of their employees. Employees who are well-equipped in the performance of their job-related tasks, will more easily deal with the ongoing need to be adaptive to change in the healthcare arena. However, those employees with no continued professional development will offer view their labor tasks as menial, inconsequential, and non-essential to the organization as a whole.

Watch our on-demand webinar, "Auditing When There Are Conflicts of Interest", for a comprehensive guide on the many areas where you’ll commonly find conflicts of interest, and how to use education to solve for these common conflicts.