American College of Physicians: Internal Medicine — Doctors for Adults ®


Lessons learned from Penn's billing problems

From the September 1996 ACP Observer, copyright © 1996 by the American College of Physicians.

By Deborah Gesensway

Members of faculty practice plans at teaching hospitals nationwide might want to heed several lessons learned by their colleagues at the University of Pennsylvania Health System in Philadelphia: Documentation in the medical record that is sufficient for clinical purposes is not necessarily sufficient for billing purposes; if charged with submitting false bills to Medicare, "everybody does it" is not a defense; and having a billing and coding compliance plan in place might save the doctors millions of dollars in fines.

Speaking to ACP's Clinical Practice Subcommittee, Mary Stein, JD, a lawyer from the University of Pennsylvania's Office of Legal Affairs, explained how the Department of Justice and Office of the Inspector General are looking at least eight other major academic medical centers suspected of submitting inaccurate bills to Medicare. (In late August, Philadelphia's Thomas Jefferson University agreed to pay $12 million for overbilling Medicare.) Many of the allegations against academic centers have to do with charging for services performed by residents without documenting the involvement of the supervising physician.

Last December, Penn's faculty practice plan, "Clinical Practices of the University of Pennsylvania," agreed to pay a $30 million fine after a federal audit found that false bills for faculty physician services were submitted to Medicare over a six-year period starting in 1989, according to the U.S. Attorney's Office. The faculty group also agreed to overhaul its billing compliance systems, including requiring all physicians to attend educational programs on billing and coding. The government's mandates would have been even tougher, Ms. Stein said, if Penn had not already developed compliance standards which the practices were implementing at the time of the audit.

Ms. Stein shared advice with ACP's committee on how faculty practice plans might learn from Penn's experience:

  • Documentation. "From the standpoint of an auditor, if it isn't documented in the record, it didn't happen," Ms. Stein said. Moreover, she said, there is a difference between what clinicians feel is adequate documentation in the chart for them to take care of patients and what is adequate documentation to support the level of service that is being billed for.

    Where it refers specifically to teaching physicians, the medical record must document that the supervising physician was present when a service was done by a resident.

  • Compliance standards. Having a program in place for complying with Medicare's billing rules can help a faculty practice plan improve how it bills overall, Ms. Stein said.

    For example, she said, many academic institutions have difficulty imposing sanctions and trouble enforcing rules aimed at changing physician behavior regarding billing because of tenure and due process issues relating to termination. Penn convinced all 600 of its doctors to comply, however, by including in its new compliance program a rule that physicians cannot bill for their services if they have failed to attend annual training sessions on how to bill.

    Under the new Penn compliance standard, all inpatient billing is done by specially trained chart abstractors in one central office. The doctors are no longer involved. For outpatient claims, however, doctors are still responsible for their own billing. A sample of their claims is audited by the central billing office annually, and if they fail this compliance review, they are given one-on-one training. If they fail again, they must pay—out of their own pockets—for a professional chart abstractor to come in and bill their outpatient charges. That can cost as much as $5,000 a month, Ms. Stein said.

  • Information and reporting lines. Ms. Stein said it is important that institutions set up special telephone lines that people can call to report suspected problems.

Ms. Stein cautioned, however, that the only thing the government finds worse than not having any compliance standards in place is to have them and ignore them.

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