An Ounce of Prevention...van Halem's Proactive Tips for Compliance

Posted on in Billing/Reimbursement

By: Pam Felkins Colbert, JD, The van Halem Group

An Ounce of PreventionAn Ounce of Prevention versus A Pound of Cure

There’s a reason “old sayings” are old sayings that are handed down from generation to generation: They are full of WISDOM and have withstood the test of time. The old saying, “An ounce of prevention is worth a pound of cure” applies to today’s health care business. If we spend an “ounce” of time and money on prevention of errors, misunderstanding, miscommunications and poor processes, we will save a “pound” of time, money and reputation!

WHAT is our Ounce of Prevention?

Being proactive rather than reactive = ounce of prevention rather than a pound of cure. Proactive steps include things like performing internal audits of your claims on a regular basis. These internal audits help avoid submitting claims that have incorrect codes/modifiers, lack supporting documentation, inaccurate patient information, claims for non-covered services, untimely claims and more. We all are aware of the “pound of cure” for failing to submit complete, accurate and timely claims: Audits, Audits, Audit -- and investigations, prosecutions, exclusions and more. The number of audits is at an all-time high from the various agencies and contractors seeking to recover funds as a result of errors, fraud, waste or abuse. The recoveries of funds are also at an all-time high. The OIG HHS reported a record breaking $4.9 BILLION recovery in federal health care dollars for 2014. The OIG HHS also EXCLUDED more than 4,000 individuals and entities from participating in the federal health care programs in 2014. CMS issued a Final Rule in December 2014 which states that under the authority of the Affordable Care Act, CMS can and will DENY enrollment and/or REVOKE billing privileges of providers and suppliers that pose a program integrity risk to Medicare. Communication is another important Proactive step towards our Ounce of Prevention. Learn from the identified errors found in your internal audits. Use those items as examples to educate and train your staff on what NOT to do as well as how to do things correctly. Make sure your staff has the educational tools to stay up to date on changing codes (ICD-9 to ICD-10, LCDs, HCPCS and CPT). Network within your industry to learn what trends are occurring, whether it is at conferences, clinics, associations or online groups. Have your internal Policies and Procedures available to employees for guidance and assurance of what and how to perform the function of their jobs. Your Compliance Officer, whether full time or part-time, is a key person for employees to go to with concerns or questions. If employees feel they have not been heard and have no one or nowhere to turn they may turn to a lawyer and the government and file a “whistle blower” case. Good communication is essential in our daily lives, and our business is no exception. Communicate often and well to prevent problems from mistakes and misunderstandings. It is more important now than ever before to be PROACTIVE in health care when providing products and services. While it seems we all have less time and less funds to do more work, a cost/benefit analysis confirms the old saying that we should invest an ounce of prevention to save us from the pound of cure.

PREVENTION: A Compliance Program Provides all the Proactive Tools you Need

CMS’ program integrity group and its contractors are shifting to a proactive process to prevent fraud and abuse verse the reactive “pay and chase.” This is being accomplished by creating a central source of data, analytics and investigations. We will see more audits of “aberrant billing,” prepay audits and suspensions of payments from CMS for Medicare and Medicaid claims. To avoid that “pound of cure,” we, too, have to be more proactive and take the above steps to help prevent providers and suppliers from getting on CMS’ radar. An effective Compliance Program is a true “ounce of prevention.” [divider style="single" border="small" color="#003777"] About The van Halem Group, LLC Our business is understanding the nation’s preeminent health care entitlement program. Since the program’s inception in 1965, its amended and growing charge has often confounded beneficiaries and providers, troubled oversight agencies, and in the worst cases, allowed for fraud and abuse within the system – costing Americans millions. Our proven experience and sound counsel, captured in lectures and publications, has uniquely positioned us as a resource to health care providers, government agencies, Medicare contractors, legal counsel, law enforcement and journalists. The van Halem Group, LLC, a division of VGM Group, Inc., has become the nation’s most respected Medicare consulting and auditing firms. Collectively, our leadership team has over 130 years of related experience. Since 2006, we have helped our clients navigate complex issues related to Medicare and Medicaid. We specialize in compliance, audits, investigations, medical review, appeals, enrollment, coding, education and training. Learn more at