Editor's note: With documentation playing a more important role than ever before in the wound care profession, this is the first of 2 installments focusing on the development of effective wound care compliance programs.
Wound care is a business. Health care practitioners are paid through the services that are provided to patients. Some clinicians may prefer, however, not to think of wound care as a business and to focus solely on what they were trained to do-provide patient care. And, that's okay. But on the other hand, some clinicians choose to provide management oversight for wound care programs. Typically, these clinicians have provided frontline wound care, then moved into a management role for their organization. Their job is to ensure that the care provided in the wound care facility is clinically effective. They must also validate that the wound care documentation supports the patient's care.
Whether a hands-on clinician or manager, it is important to be educated on the proper documentation to support history and physicals conducted, examinations completed, work performed, and services provided. This documentation translates into payment for the facility and eventually affects paychecks. For proper documentation and payment to occur, the facility must practice by a process.
Process is the thread that pulls work, documentation, and payment together. Regulations and guidelines formulated by third-party payers often dictate the actions of these threads. It is critical that all personnel associated with the performance of wound care are knowledgeable of the stated guidelines and regulations.
Health care expenditures will likely be covered by some form of medical health insurance, which requires providers to file some type of health insurance claim. The accuracy of this claim reporting, as well as supporting medical record documentation, will be imperative to recover all potential revenues and offer substantiation for the payment received. Many issues must be addressed to bring the practice of wound care into compliance with regulations and guidelines set forth by medical health insurance providers, including development of a compliance program, knowledge of specific health insurance regulations, education, and training.
The development of a compliance program will provide a structure within the organization to understand, monitor, and comply with the laws, regulations, and policies and procedures related to the performance of each individual's job. As defined by the Office of Inspector General (OIG), benefits of a compliance program include:
* effective internal procedures to ensure compliance with regulations, payment policies, and coding rules
* improved medical record documentation and improved education for all personnel
* reduction in the denial of submitted claims
* better communication and more comprehensive policies
* avoidance of potential liability arising from noncompliance
* reduced exposure to penalties
With the initiation of a compliance program, the practice should be committed to address the applicable elements set forth in the Federal Sentencing Guidelines and defined by the OIG in their publications addressing the 7 basic compliance elements:
* Establish compliance standards through the development of a code of conduct and written policies and procedures
* Assign compliance monitoring efforts to a designated compliance officer or contact
* Conduct comprehensive training and education on practice ethics and policies and procedures
* Conduct internal monitoring and auditing focusing on high-risk billing and coding issues through performance of periodic audits
* Develop accessible lines of communication, such as discussions at staff meetings regarding fraudulent or erroneous conduct issues and community bulletin boards, to keep employees updated regarding compliance activities
* Enforce disciplinary standards by making clear or ensuring employees are aware that compliance is treated seriously and that violations will be dealt with consistently and uniformly
* Respond appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate government entities
The objective for a facility/practice/department-specific compliance plan is to create a process for identifying and reducing risk and improving internal controls specific to the facility/practice/department. The plan should not in any way contradict or be in conflict with the corporate compliance plan.
The (name of wound care department) shall follow all established policies and procedures set forth in the (name of facility) Corporate Compliance Program. Because this department has included structural (framework) and substantive (regulatory) components in their development, it is found prudent that they identify their specific compliance issues.
Additional information for the establishment of a compliance program can be found on the OIG Web site: http://www.oig.hhs.gov.
*Read Part 2 in next month's issue.
Source: Hess CT. Clinical Guide: Skin & Wound Care. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.