Doug Arrington, PhD, FNP is director of the Office of Billing Compliance of UT Southwestern Medical Center of Dallas, TX.
Tell me about your work.
I am the director of billing compliance here at UT Southwestern, which means I am responsible for all the professional billing that’s done by our faculty and other healthcare providers. Also, the hospital billing that is done by our two hospitals. Also, all the research billing that is done. That’s what keeps me busy.
It was interesting to me that your background is as a nurse. Does that help you deal with billing and compliance issues?
Absolutely. It helps me in understanding the clinical situation that the providers are in, and the hospital is in, and the researchers as well. It helps me understand what they’re dealing with. It also helps me translate the compliance language, if you will, into an understandable clinical language that they can understand and apply. It makes that leap a whole lot easier for me to do with the providers.
Can you tell me about your team, how it’s set up, and how it reports?
I have a group of individuals that report to me who are compliance auditors. They are certified compliance individuals and certified coders who use the MDaudit tool from Hayes Management Consulting in reviewing the providers in the professional practice. They conduct audits on a quarterly basis of selected providers in their clinical departments that we have here at UT Southwestern. They share their findings with our providers.
I have another group from a hospital side that we do basic audits of the UB-04 claim forms that are done to ensure that the claims have gone out quickly, as well. Then I have another group that we’re just starting up right now that is on the research side, and they are in process. We’re developing our research compliance tool, which looks to make sure that we have billed a sponsor when we say that it’s a research item, and when it’s standard of care that we bill that out quickly to the third party, be it Medicare or Blue Cross/Blue Shield, or whoever it might be.
How would you say your operation compares to that of comparable facilities?
That’s a good question. I would probably say, on average I’m staffed about what most compatible large teaching organizations. I have about 1,550 active healthcare providers on the faculty side. Our hospitals are 100-and-some beds, and the other one is like 235 beds. So on the hospital side; I think for the type of audits that we’re doing on staff for the insurance side, as well.
Then for the research side, we’re just bringing that up. I’m just starting here doing the risk assessment and stuff, so I think I’m appropriately staffed for when you’re on the start up. Then as we go down, I’ll be adding additional staff as we move further into a more active auditing program. I think I’m pretty well staffed for an average organization of our size.
Can you give a high-level overview of the audits that you deal with; the RAC and the OIG audits, and what those means for hospitals?
On an annual basis I do what is called a risk assessment, which takes a look at all the different risk areas that we face here in compliance. For example, I do some data mining looking at basically, what is my top 15% in volume and cost by payer. I look both at federal payers and managed care payers. Then I also look at some data mining issues that are identified by our Medicare administrative contractor here. Then we have the recovery audit contractors and our comprehensive error rate testing, and our payment error rate measurement. Then we have the Medicare integrity group.
So we have a series of audits that are being conducted by external groups that we need to make sure we’re in compliance with. I follow them on a daily basis; go out to their sites — the CERTs, the RACs, the PERMs, and the Medicaid integrity — to make sure that there aren’t any issues.
Then obviously, every October the OIG releases their work plan that I need to be focused on. Throughout the year, they also release opinions and audits results that I need to be tuned in to and to take a look at. This applies not only to the professional practice, but also the hospital side, as well.
Then there are just general things, like the National Coverage decisions that are released by CMS, and the local coverage decisions. I need to make sure that those are programmed in to our claims management system.
Every institution has a hotline, and what we encourage our employees to do is any time they identify something that they may be concerned about is to identify that and to call us. They can be anonymous on that hotline and let us know that they are concerned about something so we can go in and do a complete investigation.
In a nutshell, that’s what I look at in building my audit. What are my priorities on an annual basis is some of those things that I take into consideration.
There’s a lot of activity out there by whistleblowers who get a percentage of the proceeds on claims that are eventually proven to be true. Did that change the way, or the scope, of what you have to do?
It certainly changes the way that I do education here at Southwestern. I make sure that in new employee orientation that we place a very high value on compliance and being compliant with federal rules and regulations. Then, for our key billing staff, we make sure that they receive at least 15 hours of compliance education on an annual basis.
We make sure that we provide ongoing education to our general population, as well. We try to do everything we can to ensure that our staff who deal with billing and coding, and our faculty members that are actually providing the service, have the necessary tools to make sure that they’re in compliance with federal rules and regulations and that they’re following the rules and regulations that we’re supposed to. Then we do audits on the back end to ensure that the claims that go out the door are going out quickly.
When the whistleblower type stuff started, that certainly changed the environment within the compliance area and made what we did, or do, on a daily basis much more visible to an organization when they see some of these large settlements occurring out there. It has something that also helps me, in regards to providing education, that I can use that to provide examples of education and why we place such a high value on it here at UT Southwestern.
If you came in cold to a hospital and were asked, “Tell us what we’re doing wrong,” What kind of things do you think you would find?
That’s a real good question. Probably, I think the hardest thing is keeping on top of the ever-changing federal rules and regulations that impact payment on a day-to-day basis, because the rules change frequently. Just about the time you think you understand the rules, we have new ICD-9 codes that come out, and we have new CPT codes that come out. CMS releases another National Coverage decision or a local Medicare releases a local coverage decision that impacts what we’re doing on a day-to-day basis. Then I have to make sure that information gets communicated down to the healthcare providers, to our claim payment systems.
That’s what I would look at in a hospital, is to make sure that they have someone who’s monitoring those things on a day-to-day basis to make sure that they have that plugged in and they’re following the rules — the CPT codes and ICD-9 regulations and stuff along that line. That would be the first thing – that I would make sure that they’ve got all that stuffed programmed into their claim payment system. That they can only bill out one of these on a daily basis and they don’t have somebody that has a keystroke error and they enter in 114 of them, versus 14 of them. You’ve got to make sure that you’ve got the appropriate fail safe on the back end to catch those types of errors. That’s what I would be looking for when I walk through the door of an institution.
You mentioned education. How much of what you have to operationalize involves having someone else do something, versus what you can do centrally?
We, on an auditing-type perspective, certainly use a little bit of that. But what we try to do is empower the clinical departments to provide education to their providers that is through the lens of their particular clinical specialty. For example, in orthopedics, I want them to be able to provide education to them that is specific around compliance issues that have the lens, if you will, of orthopedics; and then pediatrics that has the lens of pediatrics.
Being a healthcare provider myself, a nurse practitioner, I’ve learned that if somebody’s talking to me about a surgical procedure, I really have a hard time relating to that because I’m not that type of a healthcare provider. But if I’m dealing with something that I understand and I can apply it in my mind in a clinical setting to the type of patient I just saw this morning, that has a whole lot more relevance to me. That’s the reason why I try to make sure that when we provide compliance education, we’re putting it through the lens of that particular healthcare provider.
So in maternal fetal medicine, they see it through the lens of being a maternal fetal specialist. Or if it’s an urologist, they see it through that lens of being an urologist. They can understand that concept, but they understand it how it applies to them. The beauty of MDaudit is that I can build a case profile based on the risks that we talked about earlier. So I can assess that risk in urology that is specific to the urologist and I can provide specific feedback out of MDaudit that is specific to their practice in urology.
Can you tell me the toolbox of tools that you use and how they fit together?
One of the most important things I think I talked about earlier was the case profile that I built for each one of my clinical departments. What it basically does is it takes that risk assessment that I do on an annual basis, and it makes it very specific to each one of my clinical departments.
The MDaudit tool allows me to make one just for pediatrics, and one for internal medicine, and one for OB/GYN. It allows me to take that clinical lens that I was talking about earlier, and then build an audit tool around that so I can identify a specific area that they may not understand, or is a particular risk area that’s been identified by the OIG so I can make sure that we’re doing it correctly.
If I identify a problem, I can identify it as soon as possible and go in and intervene and educate before it becomes a big problem and we end up having to give back lots of money and stuff along that line. That’s the absolute beauty of the MDaudit tool is it allows me to take this risk profile, make my case profile that’s unique to my individual provider that I’m trying to identify in their clinical specialty, and then audit against that case profile.
In general, what advice would you have for hospitals and practices, related to what you do?
Keeping on top of the ever-changing regulatory environment. Make sure that you are hooked into the listservs that go out, and review the federal publications and what’s going on in the courts on a regular basis. There are a number of listservs from the compliance associations and other organizations that will help so you don’t have to go out and review the Federal Register on an everyday basis — that will actually provide that information for you.
Make sure that you have that information at your fingertips because one day that you may miss may have that absolute most important piece of information that can make the difference in your organization between doing it right or doing it wrong. If you end up doing it wrong and somebody comes back later and says, “Why didn’t you know about it?” It becomes pretty hard to defend when everybody’s looking to you to be the compliance specialist. So keeping on top of those rules and regulations is the absolute most important thing. I cannot emphasize enough.
Any concluding thoughts?
You know, I think that the compliance arena is an ever-changing environment. Education — my own personal education, as well the education as a provider — is absolutely critical. Tools that we have, such as MDaudit and MDaudit Hospital, help us communicate specific, filtered compliance education back to those providers.
I think that that’s the most important thing that we be able to do, is to provide feedback that is meaningful to that particular clinical provider. Be it a healthcare commission, or be it a healthcare institution such as a hospital or home health agency or whatever, that they can understand it through their particular lens.