The old saying that a chain is only as strong as its weakest link certainly applies to a physician’s billing staff. Knowledgeable employees will ensure proper reimbursement, but a staff with inadequate training can mean claims frequently go unpaid. A smaller practice of one to three physicians often has a longtime employee who obtained a billing position through on-the-job training, said attorney Cynthia Ransburg-Brown, a partner in the Birmingham office of Sirote & Permutt who specializes in healthcare law. However, “nothing is better than having someone who is well-versed in the practice area, in the ICD-9 codes, so that the procedure codes will appropriately match the diagnosis codes,” Ransburg-Brown said. “And when you have a well-trained staff, you of course want to do periodic in-office training sessions.” A new hire not only should be qualified for the position, but also must be able to “legitimately provide the services,” she said. “What I mean by that is that you check and make sure that they’re not individuals who’ve been barred from Medicare and Medicaid participation.” On its Web site, the HHS Office of Inspector General maintains a list of businesses and individuals who have been convicted of program-related fraud, among other things. “You can go to that list (http://www.oig.hhs.gov/fraud/exclusions.html), put in the person’s first name and last name, and if their name pops up, find out why they’re in that system and what for.” The list “definitely includes people who have convictions or who have problems with claims submission,” Ransburg-Brown said. “I would strongly urge a qualified staff that can legitimately provide the services. If you have to check them out on the Office of Inspector General Web site, then I think that’s something you should do. It’s free.” To ensure that the ICD-9 codes match the CPT codes, resulting in claims that are paid on the first submission, Ransburg suggests periodic reviews of the billing staff error rate. “Especially for a new hire who comes in, maybe 30 days after they’ve been working, look and see what their error rate may be. Take a look at some of those claims that were returned, and it may warrant some additional training. Ninety days later, check it again. You should have some improvement, of course. See if the person is continuing to improve, or making the same mistakes on coding, billing or documentation issues.” Employees also should be familiar with the error codes used by third-party payers, she said. “Someone has to be working those claims that come back, and a lot don’t work them. They end up in a little stack. ‘I’ll get to it, I’ll get to it,’ (and then it) becomes 30 days out, 60 days out. People have to be mindful of the time limits for filing claims.” Ransburg-Brown also recommends a corporate compliance plan for physician practices. “It is a voluntary program. It grew out of the defense industry when Americans were being charged $500 for a toilet seat, and the government said we need to figure out a way to make sure these government contractors are providing services appropriately and we are getting what we are paying for,” she said. “The same type of commitment to compliance is now in the healthcare industry; it has been for years. We encourage our clients to put a plan in place so that periodically you are checking up on your staff to make sure claims are being submitted appropriately. Periodically you are looking at the medical records to make sure that they accurately reflect the services you provided and that the codes reflect the services you provided.” July 2007