Anesthesiology Compliance
At first glance you are most likely thinking this is an article about formulary calculations about the respiratory system’s “Static and Dynamic” compliance. Well, my friend, you are mistaken! This application of compliance is about the realm of compliance and regulatory affairs as it applies to standards of medical care, medical record documentation, and billing practices. Are you prepared for an audit? Does your group have a truly viable compliance program? Does facility credentialing accurately reflect practitioner licensing and credentials? Is the facility credentialed for the procedures you are performing? Inversely, are you properly credentialed with the facility and your insurance payers? How are you assessing the “risk” you assumed with third party billing organizations?
A compliance program is simply the relentless pursuit of excellence. Our experience has shown the best way to infuse a compliance mentality into an organization is to make it a daily way of life. Let us begin with the basics. As a leader, you will need to mandate feedback and training as a way of life within your organization. Your primary objective is not based on a popularity contest, it is genuinely based upon a pragmatic approach to utilize auditing to identify weaknesses and areas of improvement. The process begins by opening communication within the organization. How do you begin this process? It is quite simple, begin with auditing to identify weaknesses, these weaknesses may come in many forms. You need to be prepared to accept the fact there are inconsistencies within your organization. Once you are well grounded, you need to consider auditing as a means to identifying the organizations primary vulnerabilities.
Also, a compliance program includes research into less than adequate reimbursement from insurance carriers. Additionally, includes challenging insurance carrier reimbursements and overturning claim denials. In many cases the best approach is medial review appeal. In some instances, it is necessary to communicate your concerns to the insurance carrier medial director.
Reasons to evaluate compliance as a tool:
- To fully document the scope of your compliance program – Are you including oversight of the billing operation?
- To identify and evaluate “vulnerabilities and risks” with the organization.
- To evaluate the “patient experience” from initial contact through final account billing resolution.
- How do you translate the “Zero-Defect” work environment mentality into your vendor organizations – What is your review and validation process?
- Benchmark organizations? Why are you looking for a benchmark? Why not pursue excellence and BE THE BENCHMARK!
- Define and establish practice policy & procedure documents. Examples include shoulder and knee arthroscopy, instrumentation in spinal procedures, multi-level spine procedures, cardioverter-defibrillator insertion, post-op pain blocks, medical direction vs supervision cases, E&M cases, EGDs, and colonoscopies and the list go on….
