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The following scene is a familiar one at healthcare provider

organizations across the country. Staff physicians assemble in a lecture

hall or conference room for what has been described as a "mandatory"

meeting. An administrator calls for attention and begins to speak.

"As you all know," he or she begins, "the Federal government has become

increasingly vigorous in its efforts to crack down on Medicare fraud and

abuse. Even the FBI is involved. Healthcare organizations stand to lose huge

sums in disallowed billings and be liable for even more severe penalties."

The administrator then begins explaining the extreme steps the organization

needs to begin taking to protect itself. "Working with a team of outside

consultants, we have developed a plan that will allow us to maximize

allowable billings while protecting ourselves from problems when we are

audited. Medicare has strict rules for patient care documentation. Each

physician in this room must live up to those rules."

The lights dim and a slide presentation begins. "Let's start with a simple

example. Each patient's history and physical must document a complete review

of systems. If this is incomplete, Medicare will consider the work-up

consistent with a lower level of care than that for which we billed. And the

government labels that fraud." The examples go on and include discharge

summaries, procedure and operative notes, and even daily progress notes. The

severity of illness, amount of patient contact, and documentation required

for each acuity level of billing are presented. At facilities where

residents participate in patient care, the complicated requirements for

attending physician supervision and documentation are discussed.

The meeting lasts two hours. At the end, the administrator sounds a firm

warning: "We cannot risk incurring charges of fraud and having billings

disallowed. So, from now on, we will have a strict system of supervision of

physician compliance. When a physician has a history and physical that is

deficient in required documentation, he or she will receive a warning

letter. Those with three deficiency reports will have their admitting

privileges suspended until they attend a three-hour coding seminar presented

by our consulting firm."

And so goes the physicians' introduction to Medicare billing compliance

programs. I have been part of these kinds of meetings at two different

hospitals. Colleagues report similar experiences at institutions across the

country. The details may be different, but the message of the presentation -

from the physician perspective - can be summarized in one sentence: "Our

organization has a billing compliance problem, and to solve it you doctors

must jump through these additional hoops."

This outcome has obvious drawbacks. Physicians leave the meeting feeling

unfairly singled out and demoralized. With such attitudes, their work often

becomes less efficient. New organizational and management techniques are

greeted with cynicism. Thus, a new system of billing compliance measures -

no matter how necessary or potentially effective - is in trouble from the

start.

What is the solution?

Based on the experiences of several healthcare consultants who have

developed compliance programs and numerous physicians who have had to alter

their practice patterns because of them (as well as my personal experience

on both ends of this issue as a resident physician and a consultant), there

appear to be several physician-related elements critical to successfully

implementing a billing compliance program. These elements include effective

communication, early physician involvement, ease of program implementation,

and opportunities for feedback.

Plan Communication with Physicians Carefully

Some physicians have described their introductions to compliance issues as

an "ambush." They say they felt degraded and patronized by administrators

and consultants. As one surgeon practicing at a community hospital in

Southern California put it, "As if I don't have enough problems with managed

care second-guessing me and limiting my fees, now, all of a sudden, I have

to be lectured on how to do paperwork and penalized if I don't live up to

some vague requirements." Before the compliance program even began, this

physician was alienated.

The first step to cultivating physician buy-in for these programs is not to

simply mandate physician participation, but to educate them on the issues.

Before any meetings, provide physicians with background information and an

agenda. Furnish them with the recent history of Medicare audits to let them

know what the stakes are. Give them time to digest the implications of this

information before they sit for a slide show. If physicians understand the

results of poor billing compliance, they will be more willing to listen and

to take the steps necessary to ensure that compliance occurs. Continue this

process of education as compliance programs go into effect.