July 24, 2000
June Gibbs Brown
Department of Health and Human Services
Room 5246, Cohen Building
330 Independence Avenue, SW
Washington, DC 20201
RE: File Code OIG-7-CPG. Notice: "Draft OIG Compliance Program for Individual and Small Group Physician Practices"
Dear Ms. Brown:
The American Urological Association, Inc. (AUA) submits the following comments in response to the recent Notice on Draft Compliance for individual physicians and small group practices.
The AUA recognizes the efforts of the OIG in drafting guidance intended to be more flexible and provide more specific examples of suitable compliance techniques than what had been provided in previous compliance program documents. In addition, the efforts to emphasize that innocent errors are not the areas of concern was commendable. Our comments are intended to assist in making the final document more useful, and less intimidating in the hands of the end user.
In the third paragraph of Section I. Introduction, it reads "the guidelines are not mandatory." However, throughout the remainder of the document, the tone of the language used contradicts this statement. For example, in the last paragraph of Section I.A., the draft plan states that "an effective compliance program is essential for physician practices of all sizes…." It is important to understand that to a solo practice or small group practice, such as those who make up the majority of member practices in the AUA, this document may be relied on as the primary guidance in developing a compliance program. Small practices do not have the budget to hire attorneys and consultants to interpret this guidance and draft plan documents. The typical small group compliance program will be completely developed by the physician and staff, and the document used as a guide must avoid misleading language. Explicit language should be included in the document defining what constitutes "effectiveness" in a compliance program in order to justify the costs.
Section II. B.2 provides guidance about "a resource manual from publicly available information." However, the suggested amount of directives, bulletins and other documentation is much too comprehensive to be manageable by a small practice. The amount of time and expense to gather these reference materials as listed, and to keep them current, would be prohibitive.
Keeping in mind the extent of dependence on the final draft of this document by small practices, the AUA recommends that the tips for implementation be separated from the main body of the document into an additional appendix. This avoids the impression that, to be effective, each of these suggestions must be implemented by the user. An example of how this can be misleading is found in the next to last sentence in Section II.B.3.a. This suggests that "the physician practice should also institute a policy that all rejected claims pertaining to diagnosis and procedure codes be reviewed by the coder." This may be helpful to a larger practice with certified coders on staff, but in many urology practices, the "coder" is the physician who would be forced to compromise patient care time in order to carry out this suggestion. Suggestions for implementation are helpful, but should be organized and labeled as such, in order to avoid the implication of required steps. Before publication, all suggestions should be reviewed by a panel of experienced practice management experts for purposes of eliminating impractical ideas. For example, in Section II.F.2, a suggestion is included that reads "alternatively, the repayment could be effectuated through offsets to other billings, such as undercodings." This is impractical and refutes one of the underlying principles of accuracy in coding. Practice management expertise is readily available within the staff of the professional societies and we urge the OIG to solicit more advice on practical tips for implementation of compliance programs prior to publication of the final guidance.
Despite the efforts to simplify the process and narrow the range of risk areas to be covered in this model, the time and costs associated with implementation will be significant even for the smallest of practices. For a solo physician practice to develop a program which will motivate participation by employees and physicians, the additional labor costs just to conduct training may cost thousands of dollars per year. Due to demands on the practice for patient care time, such training will, by necessity, be conducted during lunch breaks or after hours, resulting in overtime wages. Even in a situation where the practice can arrange to share the services of a compliance officer, or use the physician or office manager in this capacity, the additional costs to carry out these functions increase the overhead of running a small practice. The AUA urges the OIG to recommend to HCFA and to Congress that the additional costs of compliance incurred be reflected in future Medicare practice expense deliberations.
If the suggestions listed above are implemented, the AUA would find this document to be a more helpful guide which would encourage AUA members to develop a practice compliance program. Thank you for your consideration of these comments.
Irwin N. Frank, MD, F.A.C.S.
American Urological Association