Untangling the Web of Compliance: A Shocking Tale of Operational Inefficiencies in Healthcare

Sometimes when you hear a story it seems too far-fetched to be true. When I was contacted by a colleague from many moons back about a new C-level post she had taken, I was admittedly shocked. This seasoned executive was hired to right a ship she thought had some operational inefficiencies and was not maximizing the significant telehealth opportunity post COVID.

Several months into her tenure, she made the very difficult decision to stop nearly all billing because most providers were not enrolled with third party payers. Even worse, most had inactive DEA license status. In short, this non-profit had had a leadership team that had taken some bad advice from a long-tenured staffer. All claims were being billed under a single provider and all prescriptions written under the not always present medical director’s DEA license.

The tall task of getting all providers licensed with DEA as well as making certain CAQH files were up to date has taken months. Months of time when patients wanting to use insurance are given the choice to pay cash to see a provider today (who is not enrolled with any payers) or be willing to schedule out an appointment with the limited providers with active participation status with the patients’ insurance.

Try getting all staff to communicate a common message. Not simple. Try next to get patients to understand why last week things seemed fine (all billing was happening) but this week not so much. Not good. Talk about a Qui Tam action waiting to happen.

Bear in mind, this is not a matter of a false claim being filed because care was not rendered. It was the classic, “just bill under the provider with participation status and allow him/her to “supervise the visit” by signing off on the documentation of the non-participating provider.” In case you live on the moon and don’t read any compliance material, this is not permissible and opens the door for the “F” word. Not the offensive four-letter version but the scary one that rhymes with bawd.

And, all players... providers, leadership, billing, even clinic managers and ancillary staff... would have culpability if penalties or fines were imposed. Too many employees think no liability exists or it is capped based on the employer having Errors & Omission or Liability insurance. Know this: Any insurance like that protects the company, not the staff. Staff would end up needing their own lawyers to defend them if a case was brought.

In the end, this will get fixed and the organization will be better for it. Detect and Correct is Compliance Plan 101. However, going through the turmoil of taking the necessary corrective action is never fun and always tiresome.

If you are not certain your team is correctly or optimally credentialed and enrolled, speak up. Compliance Officers typically provide hotlines and afford anonymity (as well as protection from collegial retribution) for anyone raising a legitimate issue. Find out how to get the message to the right folks.

And, always know there are outside experts who can help expedite corrective action. Feel free to contact the folks at PMG Credentialing to see how we might assist. You will be glad you did.