Access manager role is crucial in hospital compliance programs
Access manager role is crucial in hospital compliance programs
Preadmit centers are a key area to monitor
With compliance issues looming as a growing threat to the financial health of hospitals and other providers, access managers are being challenged to take the lead in helping their institutions avoid costly violations of federal regulations. Your role in monitoring, for example, potential 72-hour "double-billing" transgressions for which hospitals continue to write huge settlement checks to the government is clear. But through involvement in preadmission testing centers and the like, access managers also may be key in more clinical battlegrounds, such as the targeting of standing laboratory orders.
Some observers say the 72-hour debacle was only a dress rehearsal for what’s been dubbed "Labscam" a federal probe by the Office of the Inspector General (OIG) of the Department of Health and Human Services. Officially known as the Lab Unbundling Project, this investigation threatens to dwarf its predecessors in terms of financial liability. For example, if your hospital has done 10,000 preprocedural tests since the changes in Medicare regulations concerning ordering of lab tests went into effect in October 1996, and those tests are found to have been ordered improperly, you could be fined up to $10,000 per violation for a total of $10 million.
"Specific to our facility, [access services personnel] are definitely the front line of defense," says Karl J. Kuppler, vice president of operations and corporate compliance officer for Trumbull Memorial Hospital in Warren, OH. "They not only initiate registration, for outpatients they do order entry, which is an important link in the compliance process making sure the proper tests are ordered and ordered properly. At least in Ohio, a big issue has been the government’s interest in bundling and unbundling [of tests]. Access managers have a vital role to play in that side of it."
As hospital administrators across the country realize that certain common medical practices, such as standing orders for basic blood chemistry, are no longer allowed within Medicare guidelines, access managers who oversee preadmission testing areas may find themselves serving as crisis control managers, suggests Jack Duffy, FHFMA, director of patient financial services at ScrippsHealth in San Diego. Hospitals "may have to completely renegotiate the intake process with the medical staff," he says. Other-wise, "there’ll be a period of time when you’re dead in the water, with no opportunity to plan things out."
Develop a compliance plan
Access managers may be called upon to ask physicians questions such as, "What’s the medical logic for that test?" Duffy points out. "If you haven’t started planning yet [for the new rules on ordering lab tests], you’re already months behind." He suggests an educational compliance program for physicians. "This may mean a significant change in the way the front end operates."
In the Midwest, Duffy says, it’s common for access managers to do order entry, and he predicts it will become even more commonplace as hospitals continue to streamline their operations. "Multi-functional people are what we’re all about we don’t just have admitters anymore and it’s worked out very well for us."
Specifics of a compliance program, he suggests, should include these components:
• Make sure that the requisition the patient walks in with exactly matches what is ordered that there isn’t an "unbundling" occurring by virtue of how tests are ordered.
• Scrutinize the registration process, the order entry process, and all related aspects, including advance directives and medical consents. The latter "are a vital part of overall processing that unfortunately are not looked at that way," he says.
As Trumbull Memorial continues to develop its compliance plan, Kuppler points out, it will go beyond reimbursement and billing and into such areas as advance directives and consents. "Once again, access managers will be integrally involved.
"Our assumption is the government ultimately will look at anything there’s a regulation on out there certainly that’s the indication," he says. "I doubt [advance directives and consents] would be a first priority, because there isn’t a big dollar value, but a well-rounded [compliance] program would be missing the boat if it didn’t take that into account."
Compliance programs should be hospitalwide, Kuppler says, addressing billing, ordering, protection of the hospital’s tax-exempt status, physician recruitment, joint ventures, and reporting of communicable diseases, among other issues. Trumbull is developing its program in five tiers, with topics falling under these headings:
• billing and financial reimbursement;
• protection of tax-exempt status;
• physician relationship issues;
• patient care and employment laws;
• "everything else," including Occupational Safety and Health Administration, environmental, and licensure issues.
This isn’t a passing fad’
After hearing representatives from the U.S. Department of Justice and the OIG speak at a recent meeting, Kuppler says he is convinced that the government’s interest in health care fraud and abuse won’t fade anytime soon. "It’s real evident that this isn’t a passing fad. In their minds they’re onto something, and they will stay with it until they’ve gotten as much as is there to be gotten."
Kuppler advises hospitals considering establishing a compliance program not to be overwhelmed by the prospect. Trumbull Memorial hired expert legal counsel to facilitate creating the compliance program and then help develop a knowledgeable in-house team to serve as a compliance committee, he says. Members include himself, the director of patient billing, the comptroller, the vice president of medical affairs, and, because of the lab unbundling issue, the administrative director of pathology.
"That gives us a broad-based team," he says, "so that someone on the team at least knows what resources are out there, knows where to go."
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