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“It takes 20 years to build a reputation and 5 minutes to ruin it. If you think about that you'll do things differently.”

Warren E. Buffet

Compliance is more than just billing correctly. It is addressing legal and regulatory standards while ensuring quality assurance, risk management, and ethical responsibility.

Emergency medicine (EM) has unique and heightened exposure to federal and state penalties because of the volume of patients treated and the ever-growing proportion of patients who are governmental insured. This is true even in small community hospitals as well as academic trauma centers.

Emergency Medicine: An Attractive Target

The federal False Claims Act (FCA) (explained in detail later) applies to any “governmental payor” which includes Medicare, Medicaid, Tricare/CHAMPUS, and the Federal Employees Health Benefit Plan (FEHBP or also known as “Federal Blue”). The FCA penalties and overpayments are based on a per claim methodology (eg, CMS 1500 claim), so the ED volumes serve to provide “a multiplier effect” for claims that are, for example, found to be “routinely up-coded,” or to have modifiers “abused” (eg, the -25 or -59), or “unbundled” procedures that should be included in the evaluation and management (E/M) service (discussed later). While these exposures certainly exist for an office-based or clinic practice, the volumes of “government” claims makes the ED an attractive target.

The Purpose of Compliance Programs

While participation in the governmental payor programs is voluntary, in a practical sense it is mandatory for EM. Compliance programs should seek to protect both the ED group and the individual emergency department physician (EDP). Medicare's provider transaction access number (PTAN) permits the EDPs services to be billed and reimbursed by Medicare—but like a driver's license, it is revocable. PTANs are issued to ED groups and EDPs in turn “re-assign” their Medicare receivables to their employed or contracted groups—and the group's PTAN is also revocable. Since both the individual EDP and ED groups' PTANs are listed on the CMS 1500 claim form, both the EDP and the group are certifying to the truthfulness, accuracy, and completeness of that claim—despite that generally neither the EDP nor the group code the chart (encounter) or send the bill for the services. The consequences of finding either the EDP or group in violation of these certification statements on the claim form could be revocation of their PTANs—effectively eliminating their ability to practice EM.

Beyond protecting the individual and group practice, compliance programs with significant resources devoted to “auditing and monitoring” (coding and billing quality assurance [QA]) should enhance the appropriateness of the group's revenue capture. “Under-coding” (coding that is lower than that supported by the medical record) is a significant issue for EM. Detecting and correcting both “under-coding” and “over-coding” are critical objectives of effective compliance program. While the federal government may care less about “under-coding” and its associated decreased ...

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