CJ Wolf
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I’ve been getting a lot of requests to do a show about coding and billing and I couldn’t think of a better guest than my friend and former colleague, Jay McVean. McVean is currently at the University of Texas Health Science Center in Houston where he is the Director of Medical School Billing Compliance. Prior to that, McVean worked at the University of Texas at MD Anderson Cancer Center with me.
I wanted to know the biggest coding and billing compliance issues in medical school, with faculty, and academic medical centers because this is where McVean’s expertise really shines.
McVean explained, “One of the biggest challenges we face in this ever-growing clinical world is our teaching physicians really must understand who they’re working with...When we’re hiring more MP’s and PA’s to help with the clinic workload, but yet the physicians also have a resident or even a medical student, sometimes the fellow rounding with them in the clinic or hospital setting, when various people are touching the notes, documenting portions of the visit, then at the end of the day a lot of the time the physicians are just really confused about if they have a TPA situation, or if this is a shared split visit if I’m in the hospital, and how much of the note to document versus maybe an MP or a PA.”
We talked about physician pressures and productivity and how it plays into billing and coding compliance. “[Teaching physicians and documentation] continues to be something that we struggle with because of the productivity that the requirements that the physicians face. Wanting to see more patients, wanting to help more folks out, but still be compliant with their notes, and getting their notes done, and then what type of attestation do they need to have. Is it a teaching physician attestation, is it no attestation at all because they are working with a mid-level, do they have a scribe working with them? The clinical room has become very congested and crowded, and sometimes it leaves the physicians often wondering, what do I do, who am I with? And it really trickles down to a documentation and compliance concern overall.” Said McVean.
Listen in to my latest episode of Compliance Conversations for a deep dive into billing and coding compliance with expert Jay McVean where we chat about teaching physicians, documentation, the complexity of the clinical environment, education and potential EMR concerns.
Episode Transcript
CJ: Welcome everybody, this is CJ Wolf with Healthicity. I welcome you to another episode of Compliance Conversations, today we have a wonderful guest, a good friend of mine, Jay McVean from Texas. How are you doing, Jay?
Jay: I’m good, CJ, how are you?
CJ: Doing great, thanks for joining us.
Jay: Thanks for having me. I appreciate it.
CJ: Absolutely, Jay. I know you’re an interesting guy, and I know a lot about you, but I’d like you to introduce yourself to our guests. Maybe tell us a little bit about where you’re from, what you’re doing, maybe a little bit about your compliance career and what you’re doing today.
Jay: Sure, yeah. I live in Houston, Texas. Work currently at the University of Texas Health Science Center here in Houston as the Directory of Medical School Billing Compliance. We have a medical school, a dental school, a school of nursing, a school of public health. Prior to that I worked at University Texas at MD Anderson Cancer Center with you, where you kind of introduced me to this whole compliance world and got me started down this whole career path. Prior to that I worked for several different organizations, private physicians, worked for some organizations doing insurance verification, coding, billing, so have my hand in just about every side of healthcare you could possibly think of, other than patient care.
CJ: Yeah, that’s right. As you mentioned you and I had some good times at MD Anderson cancer center. I know you’ve done well for yourself even since then, that’s why I thought Jay would be able to answer some good questions about coding and billing compliance. I’m glad you were willing.
Jay: I sure will try.
CJ: As I was thinking about some of the things I would ask, I’ve been doing a lot of general compliance since the time you and I were working together. At the time you and I were working together, we focused and we kind of had at the top of our heads, the tip of our tongues all the regulations and all the rules. You’ve probably kept all that, though I’m still involved in coding and billing quite a bit, it’s not something I do every single day, so I really appreciate your expertise. The first thing I wanted to ask you, you interact with a lot of other medical school compliance folks, maybe academic medical centers. I’m curious, if you had to say what the biggest coding and billing compliance issues in that area, medical school, faculty, academic medical centers, what are those biggest issues today?
Jay: Yeah, so I think not only within our organization but across other medical school campuses that I deal with, as compliance officers, I think one of the biggest challenges we face in this ever-growing clinical world is our teaching physicians really understanding who they are working with. I know you and I have had this conversation before, we have actually presented on this topic before. But it still continues to be a huge driver when we’re hiring more NP’s and PA’s to help with the clinic workload. But yet the physicians also have a resident or even a medical student, sometimes the fellow rounding with them in the clinic or hospital setting, when various people are touching the notes, documenting portions of the visit, then at the end of the day a lot of the time the physicians are just really confused about if they have a TPA situation. Or if this is a shared split visit if I’m in the hospital, and how much of the note do I need to document versus maybe an NP or a PA. That continues to be something that we struggle with because of the productivity that the requirements that the physicians face. Wanting to see more patients, wanting to help more folks out, but still be compliant with their notes, and getting their notes done, and then what type of attestation do they need to have. Is it a teaching physician attestation, is it no attestation at all because they are working with a mid-level, do they have a scribe working with them? The clinical room has become very congested and crowded, and sometimes it leaves the physicians often wondering, what do I do, who am I with and really trickles down to a documentation and compliance concern overall.
CJ: Yeah, it’s operationally, like you’re saying, the clinical environments becoming more crowded and complex as you said. Nurse practitioners and PA’s are being asked to do more and more, especially in teaching settings. Then you get residents, med students like you said. Jay mentioned that he and I presented, was that in San Diego, I think just last October, the HCCA’s, they called it the Clinical Compliance Conference, so it’s geared around these professional types of topics, we presented on teaching physician rules. If you go the HCCA’s website, you can find the past conferences and get that hand out if you’re interested. Yeah, that is a big thing, I’ve ever seen, I don’t know if you’ve seen this, where doctors have those different types of assistance, even going from one visit to the next. I’ve been in this scenario where they are working with a resident on this side of the hall, and they have a medical student on the other side of the hall, and they are going back and forth between patients.
Jay: Yeah, absolutely, and sometimes the medical students present to the attendings and sometimes they don’t. It just varies from clinic to clinic, if it’s a surgical unit versus primary care, if you’re working under the primary care exception or not. It can be extremely confusing, that leads to my next point, the actual completion of the notes.
CJ: Yeah.
Jay: Often times we go into audit a provider, and we pull a note, and the note looks complete but we get to the end of the note and the billing provider might not have signed the note, or didn’t put a teaching physician attestation, and we go back and we meet with the provider, they didn’t even know they had a note out there that wasn’t complete, or they didn’t know they had not signed it, because so many people are touching the note, the doctor, whose name is on the claim, they get overlooked in the whole process.
CJ: Yeah. With those challenges, have you found anything that works well, or doesn’t work well in trying to solve it? Is it basically you do education and try to teach the physicians, or are there mechanics that you can put in place that you’ve seen work?
Jay: Yeah, we’ve done both. As you know, back in our days of MD Anderson, just sitting in front of them with their own documentation in front of them and showing often has the biggest impact and the most benefit. We have put things into our electronic EMR flags, things that alert to the doctor every time they log in of how many notes, they have that are not complete. If they have any pending tasks, things like that. We’ve tried to tackle it from a two-front approach, education to get in front of them and show them the actual notes, also do some things electronically through the EMR system to help them with that sort of thing.
CJ: Given that, it sounds like a monumental task, getting in front of the doctors. How many providers do you have, that you are kind of responsible for, both physicians, maybe PA’s and all of those?
Jay: Yeah. My group, we have a team of six auditors, and we are looking at upwards of fifteen hundred billing providers. That could be MD’s, PA’s, NP’s, we’ve now got clinical dietitian, social workers, all kinds of varieties of different avenues that we’re auditing and reviewing now.
CJ: On that auditing and reviewing, as a director you’re overseeing it all, what are some best practices in those auditing metrics when it comes to performing the actual coding and billing audits? How many encounters do you do, how frequently, when do you do things that are randomly opposed to focusing on high-risk areas and do focused reviews of certain types of claims, or codes, can you talk to us a little bit about best metrics and practices in auditing?
Jay: Sure, yeah. Currently, we still do our random snapshot audits of every provider across the practice plan, and we try to do those at least bi-annually. It also depends on the results of the audit, if the provider did well, we may push them out a couple of years, if they didn’t do so well, we may review them again the next quarter. We’ve kept that structure in place, currently, simply because our leadership here likes the comfort that they get from knowing that each one of our providers is being looked at on a regular basis. However, we have started to shift a lot of our focus to risk-based audits. Drilling down into not only areas of risk that we’ve identified here internally, but also areas of risk that the OIG, and our max and our racks and those folks have also said are potential areas of risk. Every year in our compliance plan we try to carve out and go in and look at what are the highest ranking, or what are the things on the OIG work list that would impact our organization. What do we feel are some risks that we have already identified that we need to look at? We’re doing a hybrid model between the snapshot ten case encounters with the risk-based audits mixed in there.
CJ: Gotcha.
Jay: It’s working well, simply from the fact that we’re still able to give providers individual feedback on their own reviews, but also we can go back to our executive leadership and say hey, this was a risk that was identified on the OIG worklist, and here is how we, organizationally, are doing with this risk. Either we’re doing well, or we’re not doing well, and then what steps are we going to put in place to rectify if we’re not doing well. From a organizational standpoint, when you report up through an executive compliance committee and things like that, it really gives your program a little bit more robustness and we feel it shows them that hey, not only can we do those ten case review snapshot audits, but we do have the capability to go in and drilling down into a specific issue and looking at a larger universe of claims and making sure those are done correctly as well.
CJ: Yeah, you mentioned looking at OIG stuff, I keep my finger on the pulse of national reports that I see. I’ve blogged about a couple of different types, HBO therapy, hyperbaric oxygen therapy, I’ve seen the OIG publish two audits on those recently. IMRT, intensity modulated radiation therapy, is another one that they have published a couple of reports on. From a national perspective I think those are two you drill down on, but could you maybe comment on what you’ve seen locally? What specific types of services do you think are higher risk in your region or for your MAC?
Jay: Yeah, right now here in our area, and thank goodness it doesn’t really pertain too much to us, I would say DME is still a huge issue in the Houston marketplace, as well as ambulances, ambulance companies billing for false deliveries of patients and things that never occurred. I think one of the stats I’ve seen recently is that we have more ambulances in the city of Houston than we do taxi cabs. So, there are a lot of individual ambulance companies that are doing things not always on the up and up. One of the other unique challenges that we have here at our organization is that we don’t own our own hospital. We staff a couple of hospitals here in the city of Houston, but we don’t bill the facility charges, or just worry about some of those bigger facility ticket times that other organizations would have. We have a huge practice plan, where we’re ideally billing E/M type visits where some outpatient procedures and testing and things like that. When you get into things like IMRT and those type of things, those services don’t really pertain to what we do in our organization.
CJ: Gotcha, but you have every physician specialty under the sun probably, right?
Jay: Absolutely. We cover from one end of the rainbow to the other.
CJ: Yeah, interesting. Let me ask you this. You talk about auditing metrics, that sort of thing. Doing your standard audits for every doc, also risk-based. Let’s say you’ve identified one or two. Or I don’t know, maybe there’s a few, that are regularly failing these coding or billing audits. What have you found that works well, as what doesn’t work, when you’re trying to help those providers that you’ve identified as potentially failing?
Jay: Yeah. What I’ve found is it really boils down to physician leadership within the department, and how much of an emphasis they place on compliance. If they have strong leadership in their department and we notify a department chair that a provider has not done well on a review and we educate that provider. If that department has strong leadership, typically those problems get corrected and rectified quickly.
CJ: Gotcha.
Jay: In areas where there is not so strong of leadership, and physicians that really push the compliance factor, often times we see those as repeat offenders, the ones we keep going back and educating and teaching and training, and getting face to face meetings with, and showing them where they have gone wrong, or their documentation is missing. It really, not only at our organization, but as I have talked to other folks in the academic world, physician leadership, and physician driven compliance is a valuable tool. If you have those physicians that are well respected and they push compliance, they talk to their more junior faculty on things like that, it really goes a long way.
CJ: Yeah. We are getting kind of close to the end of our time. I wanted to ask a follow up on that, tell me a little bit, I know this was big when you and I worked together, that relationship building, getting physicians to trust you. What have you found that works well, or that you fell flat on your face, I’m not going to do that approach again?
Jay: Yeah, I think you hit the nail on the head. It is all about relationships. My team and I, we approach physicians as if we are in a customer service business, where we are trying to help them. We want them to see us as a resource. We’re not someone that is going to get them in trouble. We make it a good point that physicians understand that we’re not the compliance police. We’re here to help them, and keep them out of trouble with the government, and keep our organization out of trouble. When we email a provider to meet with them, we make sure to use the words review instead of an audit. It’s been my experience that when I use the word audit, the fences go up, and they think they are in some sort of IRS audit and think they are in some sort of deep trouble, and it can be a little challenging to schedule a meeting, or walking in with a buzz saw with some of these guys. If you approach it from an angle of, I’m here to help you, I’m here to teach you, I’m here to work with you. You know CJ, as you know, I’ve done everything from everything of going around in clinics with providers to better understand what it is they are doing because the coding rules don’t always match up well with the clinical situation, the clinical scenario. Sometimes you just need to put your boots on the ground, go in there shoulder to shoulder with them, watch what they are doing. Then go back and explain, teach them, okay here is what you’re doing, here is what the rules say you need to do, how do we make those work together. For clinical flow, for operational flow, so they can still see the maximum number of patients that they will need to see per day. Patient quality is still there, but we are meeting all our documentation and billing compliance guidelines and criteria. I’ve found that’s been the best approach, to really get in there and say, I understand what you’re going through. Let me see what I can do to help you. If you put yourself in their shoes, often they respect you more, they want to work with you more, as opposed to fighting against you and saying these rules are just stupid, and why do I have to follow them.
CJ: Yeah, kind of the mantra of seeking first to understand, and then to be understood yourself.
Jay: Absolutely.
CJ: As you said, put yourself in their shoes, even if you think you already know the answer, it’s just good relationship building, when they can feel and sense that you’re willing to look at their perspective first before you offer your solution. They need to feel that they are heard, and then you can share what you’re going to do, even if you already know what the results going to be. You and I learned that that’s why I’m asking the question because I think it’s still a truth. That we all need to pay attention to. I’m glad you’re reiterating that. This time has just flown by. I really appreciate your insight, Jay.
Jay: No problem.
CJ: Appreciate your willingness to be on the podcast. Maybe we could have you on as a guest again, and I’m sure you and I will present again at other conferences, thank you so much.
Jay: Thank you CJ, appreciate the invite, and absolutely, anytime you want to talk about this I’m more than willing.
CJ: Awesome. Thank you to all of our listeners to listening to another episode of Compliance Conversations, this is CJ Wolf signing off, and until next time, have a great day.
Questions or Comments?