A trade group for medical records professionals has outlined a model plan for complying with the laws, regulations and policies that govern reimbursement for healthcare services.
The model, designed by the Chicago-based American Health Information Management Association, covers the identification and management of data required to document and justify billed services.
It also proposes and includes a job description for a compliance specialist in healthcare information.
The specialist, who ideally would report to the organization's corporate compliance officer, would oversee efforts to ensure accurate medical coding, including corrections of problems revealed by monitoring and auditing.
The 80-page instructions and supporting information concentrate on "a key critical component of a compliance program," said Sue Prophet, author of the model program and director of classification and coding at the AHIMA.
The broad brush strokes of a corporate compliance program are outlined in a series of guidelines issued by the federal government to help providers head off charges of reimbursement fraud (Feb. 16, p. 14).
Billing and coding represent one aspect of a model corporate effort that also scrutinizes such departments as the business and admitting offices for evidence of Medicare kickbacks and abuses in marketing and cost reporting, Prophet said.
The AHIMA document spells out the details in some of the guidelines issued by HHS' inspector general's office, she said. For example:
* The federal government says appropriate documentation should accompany all bills, and hospitals should submit claims only for "medically necessary" services. The AHIMA model walks managers through appropriate documentation and explains the paramount role of physicians in supplying the written evidence of medical necessity.
* Federal guidelines call for periodic training and education of employees. The AHIMA document specifies the type of education and retraining necessary, from the classification of services to the impact of medical coding on the clinical, operational and financial aspects of healthcare delivery.
The model plan also delves into auditing a compliance program's effectiveness, enforcing rules, disciplining employees for violations and responding when potential problems or unusual billing trends are discovered.
"An organization must be able to demonstrate that it is actually doing what its written program says it is doing," Prophet wrote in the publication. "The federal government considers an ineffective program, or one that exists only on paper, as being worse than no compliance program at all."