cus for the coming year. Areas of interest
in this year’s plan include assessment for
chronic care management and payments;
comparisons of payments between pro-vider-based clinics for payment comparisons; prolonged evaluation and management (E/M) services; electronic health
record (EHR) incentives for meaningful
use (though this has, thus far, been aimed
at larger health systems and hospitals);
and the Physician Payment Sunshine
Act to assess how physicians responded
to payments from pharmaceutical companies in their patient care choices.
Do I need to do anything
with my practice?
Compliance programs are
required for all medical offices, even
small practices. They can be scaled to
the office’s individual needs. These pro-
grams create systems within the office
setting to detect and correct potential
fraud and abuse. Though there is no
specified method of creating a program,
the OIG has recommended seven “el-
ements” to consider in designing one:
•Conduct internal auditing and
• Establish written standards for your
• Designate a compliance officer (or
• Educate and train staff.
• Maintain open lines of communication among clinical and office staff.
• Enforce disciplinary standards.
• Respond appropriately to identified
issues with corrective actions.
An effective program should be writ-
ten, distributed and understood by all
members of the practice and have real
consequences for inappropriate or sus-
pect behaviors. Compliance programs
placed “on the shelf” and not followed
will be viewed as violating the spirit of
the law and may be used to demonstrate
that the practice was aware of its obliga-
tions but failed to follow them.
I want to avoid problems.
Where do I start?
Internal audits are an important aspect of compliance programs
and are a good starting point for practices wanting to do self-monitoring. Some
guidelines for the process might include
obtaining productivity reports from
your billing department, separated by
provider, and estimating distributions
of E/M codes.
Using 12 months of data allows for
seasonal variability and will produce
a more accurate picture of how your
practice and providers code and bill for
services. When reviewing actual records
from each provider, look at the billed
services and the documentation for
those services to verify the codes/mod-ifiers, documented services and billed
charges match. During this review, it
is prudent to determine whether the
records (EHR or written charts) contain pertinent patient information such
as name, dates for services, appropriate
demographic information and allergies,
and accurately captured services. Clear
outliers or particular charges that seem
to be miscoded or billed frequently can
be addressed via processes outlined in
your compliance program.
Take home messages
• Be aware of office processes and
practices that can leave pediatricians
vulnerable to accusations of fraud
and abuse and place them at risk
for fines, licensure issues, exclusion
from payers and criminal liability.
• The OIG and private payers will be
scrutinizing more office-based settings. Prepare now to identify and
respond effectively and swiftly to
• Written compliance programs are required for all practices, big and small.
• Coding at a lower level of care than
warranted by the services provided
in an attempt to stay under the radar
with payer audits can backfire because any coding outliers can trigger
scrutiny. Accurate coding should be
• Internal audits can uncover provider
issues, allowing you to address them
in a comprehensive manner within
your practice’s culture. If you don’t
have the resources or expertise, audit
consulting services are an
Dr. Scibilia is a member
of the AAP Committee
on Medical Liability and