Hair-Rising Compliance Advice from Halloween Carl

Carl is embracing the spirit of Halloween and taking a walk on the wild side. But never fear – the Angel of Compliance is always near!

As you navigate the ever-shifting minefield of compliance advice, you’ll find your fair share of tricks AND treats. But how do you know which advice is frightful and which is delightful? Carl is here to make sure bad advice doesn’t haunt your compliance program.

[Devil Carl]: “Just correct the problem moving forward.”

[Angel Carl]: “If only this was an appropriate approach. But alas, only correcting the problem moving forward (without also looking back) can put your organization at serious risk.”

Let’s consider a hair-rising scenario: imagine you’re performing a routine billing audit of a physician’s professional charges. You decide to include a good proportion of claims with modifier 25. If you recall, modifier 25 allows reimbursement for an evaluation and management (E/M) service on the same day as a procedure.

Without the modifier, both services will not be reimbursed. Assume all the selected claims with modifier 25 were determined to be inappropriate and those funds needed to be returned. The 60-day overpayment rule requires an organization to go back six years when they’ve identified an overpayment.

In this situation, because the routine audit identified a provider who was incorrectly using the modifier, the 60-day overpayment Final Rule would define this as identifying an overpayment that would require a six-year look back with 60 days to return the funds, otherwise the claims could meet the definition of an “obligation” under the False Claims Act.

[Devil Carl]: “Who needs a compliance program when you hire honest people?”

[Angel Carl]: “There’s no magic spell that gives your organization an understanding of our complex regulatory environment (despite how hard we may wish for one). Ethical people are great, but you need ethical AND knowledgeable people to maintain compliance.”

Compliance requires a skill-set of maintaining a working knowledge of regulatory and legal changes that affect an organization’s business or mission. Even honest and ethical people can fall out of compliance on a new regulation or rule simply because they didn’t have the time or expertise to keep up with the changes.

Don’t heed this advice – it doesn’t recognize the broader area of compliance expertise beyond the important concept of doing what’s right, ethical, or honest.

[Devil Carl]: “Anyone can audit that.”

[Angel Carl]: “Allowing just anyone to perform an audit can be the stuff of nightmares!”

The skills that a good auditor develops over years of experience are generally transferrable to other domains that need auditing. These general skills include audit process, independence, and reporting to management. However, more and more compliance programs need to perform audits that require specific content expertise such as billing, coding, reimbursement, medical necessity, anti-kickback, Stark and HIPAA.

Good auditors can be helpful in the general skills area, but not every auditor will have the content expertise needed for each of the various audits mentioned above. Make sure your auditors know when they might need a second opinion when it comes to content-specific expertise.

You never know what bad advice might be lurking around the corner. Remember, knowledge is power! Don’t let some scary advice keep you up at night.

Compliance Advice from Angel Carl & Devil Carl


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