A Senate hearing on what witnesses agreed is a small number of medical business consultants providing physicians with illegal advice has prompted industry leaders to defend the integrity of their profession.
Billing, coding and compliance professionals insist that the majority of their peers are honest and offer physicians only legitimate services and guidance.
There are a few rotten apples, they admit, but also credentials and references that providers can use to discern the good from the bad.
Robert Hast, director of investigations for the Government Accounting Office, presented highlights from a recent GAO investigation into unethical and illegal consulting practices at the Senate Finance Committee hearing June 27. Hast reported examples of two workshops where consultants instructed physicians how to document higher levels of service than were medically necessary to justify increased billing of private insurers and government programs.
The investigators targeted consultants who advertised that they could enhance revenue and avoid audit.
Tape-recorded segments of these sessions supported testimony from Sacramento, Calif., family internist Kathryn Locatell, M.D., who participated in the investigation. The tapes detailed instances where consultants advised physicians and medical groups not to return overpayments, to upcode insurance claims and to limit access to Medicaid beneficiaries.
"If the sound bites that I heard are true, and there are no other explanations for their suggestions, that's totally inappropriate," says Roy Snell, CEO of the Philadelphia-based Health Care Compliance Association. The association has 3,000 members who are compliance officers, lawyers, billing coders, administrators and physicians.
"Most consultants are fastidious with their advice, almost religious about following the rules, particularly coding consultants," Snell says. "The predominant personality is that of a zealot for accuracy in following guidelines and regulations."
Sen. Charles Grassley (R-Iowa), a senior member of the Senate Finance Committee, decried the lack of mandatory accreditation or certification for healthcare consultants.
Snell, however, points out that HCCA and other groups have developed rigorous voluntary certification programs. The American Health Information Management Association, a trade group with membership exceeding 40,000 health information specialists, also offers four levels of credentialing, based on education and exams, that qualify individuals to give billing and coding advice. All are bound by AHIMA's ethical code of standards for professional behavior.
"My wish is that we'd stop saying the words 'revenue enhancement,'" Snell says. "It is irrelevant. If you say we are here to help you bill correctly, you've covered everything and will not be misunderstood."
While there is no clearinghouse for information on consultants' backgrounds like the National Practitioner Data Base for physicians, the inspector general's office does maintain a list on its Web site of all parties that have entered into corporate integrity agreements (CIAs). These are individuals or groups that agree to resolve outstanding or potential liability, return overpayments and install policies and procedures that ensure their employees and contractors understand how to behave.
In billing cases, providers or consultants who sign CIAs must offer specific training in the area of billing conduct that brought them to the inspector general's attention in the first place and provide the office with internal and external audits to document compliance progress. When the terms of the agreement have been fulfilled, that party is removed from the list.
The HHS inspector general also has posted on the Web a special advisory bulletin warning providers about how to recognize and steer clear of questionable advice; go to oig.hhs.gov/advopn. For a current listing of CIAs on the Web, go to www.hhs.gov/oig/cia/ciacurrent.htm.
Lewis Morris, assistant inspector general for legal affairs for HHS, testified before the Senate committee last month. In an interview, Morris said some consultants vying for physicians' business are preying on the "misconception that the government is in the business of going after doctors to put them in jail."
"If they're selling fear, it's easier for doctors to put themselves in the 'good hands' of these consultants," Morris says. "Doctors need to take a deep breath and bring a healthy skepticism to anyone who promises a guaranteed return."
Robert Burleigh is chair of the ethics and compliance committee of the Laguna Beach, Calif.-based Healthcare Billing & Management Association, a trade group representing 640 third-party medical billing companies that provide services to more than 7,600 clients, mostly medical practices.
Burleigh expresses concern that excessive attention and over-reporting of a limited problem could create hysteria among already apprehensive providers.
He questions why Morris, in his testimony, brought up the 7-year-old Metzinger Associates case, in which two New Jersey consultants improperly advised more than 100 hospitals to unbundle clinical laboratory tests to maximize reimbursement.
"We want to make providers nervous about their own behavior, and now we make them nervous about who they get advice from," says Burleigh, who also is president and CEO of Brandywine Healthcare Services, a consulting company in West Chester, Penn. "What's next? The government saying, 'Trust us, we're here to help you'?"
Morris, in defense of citing the settled case, says: "All I can do is talk to our historic experience. As I attempted to make clear in my testimony, we don't think the vast majority of consultants, any more than the vast majority of providers, are dishonest. It shouldn't be a shock that we don't have hundreds of examples."
Could merely attending the seminar of a consultant who gives improper billing and coding advice subject a physician to investigation?
Hast of the GAO testified that his office has discussed with the inspector general's office the need to monitor workshops and seminars similar to the ones attended during the recent investigation.
"The OIG isn't going to subpoena the Rolodexes of every consultant, but some are known to us," Morris says. "Certain consultants get a reputation for being sharpies, and we hear about them. If a provider goes in looking for someone to help them game the system, they put themselves at risk."
Georgette Gustin is president of the National Advisory Board for the American Academy of Professional Coders and a director of the healthcare consulting practice in the Indianapolis office of PricewaterhouseCoopers. She emphasizes what should be obvious: A physician or group should always get a second opinion when advice sounds questionable. She uses the common comparison to the IRS and tax advice, saying if something doesn't feel right, a qualified advisor should be able to check source material and provide citations.
"If (physicians) are looking at contracting with somebody, they need to get resumes," Gustin says. "Are they credentialed? Do they really understand that specialty niche? Check and call their client references. A good consultant with reputable experience and background will have good references who can speak to their technical knowledge."
Burleigh argues that excessive and unclear regulation could be the culprit, that confusion, not criminal intent, may result in controversial decisions because "the line (marking what is illegal) is in pencil and rarely ever straight."
"I'm engaged in a profession that shouldn't exist," Burleigh says. "It shouldn't be necessary for healthcare providers to hire someone from outside their practice to navigate federal regulations."
The AMA agrees and is sponsoring identical versions of the Medicare Education and Regulatory Fairness Act in the House and Senate. Part of the bill puts the onus for compliance education for providers more squarely on the shoulders of the Centers for Medicare and Medicaid Services.
Donald Palmisano, M.D., an AMA trustee, says the group "strongly opposes consultant courses that suggest fraudulent billing practices." While the AMA works with screened consultants to offer coding and reimbursement seminars of its own, through its KnowledgeLink program, the organization does not credential consultants. In fact, the AMA is supporting legislation to make the government more responsible for educating physicians about compliance.
"Physicians who must comply with the complex Medicare policies should be able to turn to government-sponsored education efforts--not hired consultants--to help them understand the complexities of the Medicare program," Palmisano says.