Unconventional Wisdom Regarding Compliance Issues

Unconventional Wisdom Regarding Compliance Issues

Sticking with the crowd often feels safe. But simply doing what everyone else is doing is not a substitute for analysis. 

I’m going to give you a peek inside my brain today. It may be a bit scary, and it may make you wonder what it has to do with compliance, but trust me: it will tie in.

I still wear a mask in most public settings. I’m not immuno-compromised, but I do know a number of previously very healthy people, including family members, who have had long and slow recoveries from COVID-19. I also really don’t enjoy being sick. Or, put another way, I like being healthy. The mask has a very low cost to me. I don’t avoid anything I want to do. I still eat in restaurants. When I’m talking to a colleague who relies on lip reading, the mask comes off. In essence, I’ve made a cost-benefit analysis and balanced risks.

But many people look at me like I’m crazy. People often ask, “why are you wearing a mask?” Now, I’m sure some of those people have engaged in their own cost-benefit analysis. Some probably hate the feel of a mask. That’s totally cool. But I suspect that many of them haven’t actually assessed the risk. Instead, they’re simply doing what everyone else does, and assuming that anyone doing something outside the norm must be wrong. That is a really crummy way to make decisions.

Now, let’s put it in a healthcare compliance context. Many of you have heard me say that when doing a refund, Medicare only requires you to go back 48 months, rather than the six years most people use. Have you critically considered that, or have you dismissed the argument because it’s not what most people do? I’m absolutely comfortable with the legal analysis. If you want a copy of it, send me an email and I’ll shoot it to you, totally free. I’m confident it’s right; it’s just not what everyone thinks. (Quick aside: I charged a client $170 last week to send an email that will likely save them $5 million because of that refund analysis. Yes, a $170 bill to save $5 million. If you think lawyers are always too expensive, that is good cause to reconsider.)

Let’s go over two more healthcare compliance examples. Many years ago, a variety of organizations fell victim to coding consultants offering contingency deals. When the coding consultants gave improperly aggressive advice, their clients were dragged down with them. Many of the organizations figured since others were doing the same thing, it had to be right.

Organizations dismissed a risk because they were using polling, rather than analysis, to decide. On the other side of the coin, consider the many organizations that refunded money for short hospital stays in the period before the Two-Midnight Rule. There, consultants were pushing InterQual and then Milliman (now MCG) criteria.

Organizations that refunded failed to understand that Medicare hadn’t established a standard for inpatients, and they had absolutely no duty to refund. Instead of making a critical analysis, they once again relied on the herd.

Here’s some irony that reveals how flawed snap judgments are.

Some people will look at my mask and conclude I’m unreasonably cautious, while some of those same people may consider me a crazed, careless kook, based on my legal analysis. I’d like to think that both conclusions are wrong. But I know this. When you’re analyzing compliance issues, or deciding how to live your life, what everyone else is doing is darn near irrelevant. As the Monroes ask “what do all the people know? I recommend we all take the advice of Fleetwood Mac. Go your own way. As long as you do it while thinking critically, you won’t have to call it another lonely day.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

David M. Glaser, Esq.

David M. Glaser is a shareholder in Fredrikson & Byron's Health Law Group. David assists clinics, hospitals, and other health care entities negotiate the maze of healthcare regulations, providing advice about risk management, reimbursement, and business planning issues. He has considerable experience in healthcare regulation and litigation, including compliance, criminal and civil fraud investigations, and reimbursement disputes. David's goal is to explain the government's enforcement position, and to analyze whether this position is supported by the law or represents government overreaching. David is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

Related Stories

Get Ready for HCPCs: Here’s an Update

Get Ready for HCPCs: Here’s an Update

The Centers for Medicare and Medicaid Services (CMS) has released a summary of each HCPCS Level II code application decision. The document is twenty-eight pages

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Preventing Sepsis Denials: From Recognition to Clinical Validation

Preventing Sepsis Denials: From Recognition to Clinical Validation

ICD10monitor has teamed up with renowned CDI expert Dr. Erica Remer to bring you an exclusive webcast on how to recognize sepsis, how to get providers to give documentation that will support sepsis, and how to educate to avert sepsis denials. Register now and become a crucial piece of the solution to standardizing sepsis clinical practice, documentation, and coding at your facility.

August 22, 2024
Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Optimize your inpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. Participants will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

June 26, 2024
Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P., as she helps you navigate advanced inpatient CDI technologies, regulatory changes, and system interoperability. Angela will provide actionable strategies for integrating AI and predictive analytics into CDI practices, ensuring seamless system interoperability, and maintaining compliance with evolving regulations. Attendees will learn to select and implement advanced EHR systems and CDI software, leverage data analytics to enhance documentation accuracy, and stay audit-ready with the latest compliance updates. Real-world case studies and practical tools will empower you to drive continuous improvement in CDI, improve patient outcomes, and enhance organizational efficiency. Don’t miss this opportunity to advance your CDI practices and stay ahead in this dynamic field.

July 11, 2024
Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P, for an insightful webcast on improving inpatient clinical documentation integrity (CDI). Inaccurate documentation can lead to misdiagnosis, improper treatment, and compromised patient safety. High workloads, lack of standardized practices, and outdated EHR systems contribute to these issues, affecting care quality and financial outcomes. Angela will offer practical strategies and tools to enhance accuracy, consistency, and timeliness in documentation. Attendees will learn to use standardized templates, checklists, and advanced EHR systems, while staying compliant with regulations. Improve patient care, ensure accurate billing, and reduce audit risks with actionable insights from this essential webcast.

June 26, 2024

Trending News

Featured Webcasts

Pediatric SDoH: An Essential Guide to Accurate Coding and Reporting

Pediatric SDoH: An Essential Guide to Accurate Coding and Reporting

This webcast, presented by Tiffany Ferguson, LMSW, CMAC, ACM, addresses the critical gap in Social Determinants of Health (SDoH) reporting for pediatric populations. While SDoH efforts often focus on adults, this session emphasizes the unique needs of children. Attendees will gain insights into the current state of SDoH, new pediatric Z-codes, and the importance of interdisciplinary collaboration. By understanding and applying pediatric-specific SDoH factors, healthcare professionals can improve data capture, compliance, and care outcomes. This webcast is essential for those looking to enhance their approach to pediatric SDoH reporting and coding.

August 8, 2024
Oncology and E/M Services: Compliance, Medical Necessity, and Reimbursement

Oncology and E/M Services: Compliance, Medical Necessity, and Reimbursement

Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, VP of CDM, for a webcast addressing oncology service coding challenges. Learn to navigate coding for infusions and injections alongside Evaluation and Management (E/M) services, ensuring compliance and accurate reimbursement. Gain insights into documenting E/M services for oncology patients and determining medical necessity. This webcast is essential to optimize coding practices, maintain compliance, and maximize revenue in oncology care.

July 30, 2024
The Inpatient Admission Order: Master the Who, When, and How

The Inpatient Admission Order: Master the Who, When, and How

During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.

June 20, 2024
Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.

May 21, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →