Episode 6: Basics of a Compliance Program

Richard: Welcome back to Agile&Me a Physical Therapy podcast series, a podcast device to help emerging and experienced therapy leaders Learn more about various topics relevant to outpatient therapy service. Today's podcast is titled Basics of a Compliance Program, and our guest is Tiffany Warden. Tiffany is currently the clinical compliance officer for Alliance Physical Therapy Partners. Welcome Tiffany.

Tiffany: Thank you, Richard.

Richard: What I'd like to do before we dive into the details and learn about compliance programs, would you be so kind, is to introduce yourself to the listeners.

Tiffany: My name is Tiffany, and in 1998 I graduated from the University of Missouri, St. Louis with a bachelor's. I worked for about five or six years with the Department of Corrections and figured out that I needed to maybe move a little bit on in my career to something a little bit more challenging and started looking around and developed an interest in working in the medical field. So in 2003, I resigned my position with the Department of Corrections, and I went ahead and went after a certification in medical coding and billing 2005. I did complete the program and became a certified professional coder, and I began working for a local PT practice in Missouri as a claims manager. After a couple of years, again I started looking for new challenges within my current organisation and eventually, Talk them into reorganising their annual regulatory training program and their medical records production program and their credentialing programs. I went on to review their OSHA programs and their medical needs and DME provider programs, and just finally figured out that my forte was in evaluating programs and implementing changes that streamlined the process and, and followed all the regulatory requirements that they were required to follow. In 2013 agility Hill hired me as their outpatient compliance officer, and that following year I actually went back to school and obtained my professional compliance officer certification. And I now serve as the compliance officer for Alliance Physical Therapy Partners. And I oversee our compliance program as well as the medical records and credentialing departments.

Richard: What actually is the role of a clinical compliance officer? I'd love to know a little bit more about what the duties, responsibilities are of such a position.

Tiffany: Yeah, it's an interesting position because from a high level, you have to act as sort of the guardrails of the company. You have to know enough about each area of compliance, your coding, your billing, the administration side of it, the clinical activities, risk management, and so on. You've gotta know a little bit in every area in order to develop a program to where you are effective. As I said, the guardrails for that company, making sure everybody stays on the same general path and is following the same general rules in order to achieve what we believe is the most compliant and ethical way to run that business.

Richard: Yeah, you make it sound so simple. I kind of have those guardrails or bumper bars, whatever one wants to call them. Obviously there's a lot to do, the job. What type of responsibilities does the clinical compliance officer have? We talked a little bit about the kind of the role, but what, what, what are the responsibilities?

Tiffany: I would say the main responsibility is, So not only do you have to have that high level awareness of all of the areas where you know, compliance, where you have a compliance risk or legal risk, you've got to make sure that you are educating your staff and, and the rest of the members of your company on where those risks lie and how to avoid those risks. It's easy. To say that, well, everybody follows the rules and nobody gets into trouble. But again, you said the herding cats reference. It is when you are running a larger company, you're dealing with different people in different roles, clinical, non-clinical, and so on. And so you've got to get everybody on the same page and educate in those areas to make sure this is where you need to be operating. Where it is within those guard. =========================

Richard: When I worked in hospitals the threat of the compliance officer was always kind of an ominous threat, or seemed to be. I always found it strange to call them officers almost, where, like you said, really the primary role is to educate and to coach and kajo and to encourage. And only a small part of it truly is what I would say policing. Would you agree with that?

Tiffany: I would agree with that because if you educate a working staff properly, you really minimise the amount of that policing that you have to do on the backside of things.

Richard: The first question, a lot of certainly smaller practices would, would ask is, why bother, why do I need a compliance program? It's a distraction. It takes time away from patient care. How would you answer that?

Tiffany: I think it's all in how you look at it, and so I always try to approach it from the point of view that if I know the rules, I know what I can do and I know what I cannot do, and I like to focus on what I can. Again having that education, having that knowledge, it just allows you, even in a smaller practice, if you know where your guardrails are, if you know where you have to stay on the road, because you know as well as I do in some of, in some of the smaller practices, these clinicians are pulled in a thousand different directions and oftentimes it's very easy to get pulled off. You pull your focus off what it is that you should be doing, and you're just distracted by these little things that probably matter. Right. But it doesn't matter as much as the overall idea of getting somewhere in a compliant and ethical manner. And so I like to approach it from that perspective.

Richard: yes. It shouldn't really be a question of why do I need one? It's really a question of do I want to have a business or not? In order to have a business and for it to, to continue to exist, you really have to focus on compliance first and foremost, don't you? It's left, right and centre.

Tiffany: That is true. That is definitely true.

Richard: I always say when they're talking to clinicians, one has to operate a compliant quality business in a fiscally responsible manner, and there's a reason why put compliance at the front, because if you're not compliant, you can't deliver care and you won't have the doors open. So everything else is academic unless you have that first foundational piece. Would you agree?

Tiffany: I would agree with that. What external entities do we have to be in compliance with? So we talk about compliance as being a topic, but also we have to be compliant with third parties. Is that right? And which ones might they be? You have to consider that you're operating on essentially three levels. The federal level, the state level, and then sometimes your local level, your county level, or city. I guess from a federal level, I would always focus on the Office of Inspector General. They oversee, you know, any issues that happen with Stark, any issues that happen with kickback the anti kickback statute and any of those federal laws, fraud, waste, abuse. These are the guys that are always. Looking and auditing and making sure that the providers are following and are in compliance with those guidelines. The good thing about them is that they publish a work product every year and how that helps us is that it literally is a list of items that they're looking at. And it's always based on the previous year's activity. And if they notice a trend or a topic that is continually coming up with providers or if there, or failing audits in specific areas, they're gonna put it on the list. And so if you just go out and you take a look at the list, they might seem like a big scary organisation at first, but they are handing. Everything you need to know about what they're going to be looking at and maybe where you can start looking internally for ways to improve your process and your outcomes. Another one, of course, is CMS. Nobody can target CMS. It brings Medicare Part B and their rules are enshrined within regulations. And so when we consider that we are essentially, when we follow Medicare rule, we are actually following the such, you have to consider that that bleeds out into your other federal programs, so your tri cares and champs and your tri West and veterans, and so on and so on. So that covers a long list of insurances, including Medicare Advantage programs that are offered by private insurers. Those guidelines and rules actually apply down the line. So that's always a good place to go and pay attention to because everything's published for everyone to take a look at and read. Everybody has access to it at cms.gov and it applies pretty much across the board. Well, I think the big bad, if I can call it that, is the Office of Civil. And civil rights encompasses HIPAA and HIPAA is sometimes this area where you think if you keep your patient's information private, that you're good to go. But there's so much more For HIPAA, it's not about just keeping it private, it's about how you store it, how you send it, how you transmit it, how you retain it, any number of things.

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Richard: Welcome back to Agile&Me a Physical Therapy Leadership podcast. Obviously if we are not compliant, there are consequences. What type of consequences are there, depending on non-compliance, if that makes sense.

Tiffany: Well, I think the two that are at the forefront of everyone's mind are an audit. So you're engaging in a billing practice or a coding practice or a collections practice, it's a little bit skewed outside of the normal. Expectations for, for your provider type, then you're gonna call attention to yourself, whether it be for Medicare or one of the bit skewed outside of the normal. Expectations for, for your provider type, then you're gonna call attention to yourself, whether it be for Medicare or one of the other federal agencies or even a private payer, because private payers have their own sense of rules and regs that we have to follow. So you call attention to that and you could instigate an audit, which almost always instigates a payback. And so there's that. Incentive to stay on the right path and to, and to continually always try, to do that right thing. The other part is you look at those agencies we just talked about. You look at OCR, These entities have the ability to bring charges against not only the companies, but the individuals within the companies. And so whether, whether they be a civil charge or a criminal charge, it's no longer just the big players that are at risk. It's the individual players within the smaller businesses that are at risk because everybody is a stakeholder in creating a culture of compliance in any given company, and everybody's expected to part. And be knowledgeable about what it is that they're expected to do.

Richard: There's certainly some severe and serious consequences that aren't there if we don't follow the rules, and that's not whether there are no excuses there with regards to, well, know. Doesn't matter if there is an intent or not. They still suffer the consequences of non-compliance.

Tiffany: That is very true. The assumption is if you are in this business, it is your business to know what the rules are, and intent is not necessarily considered in some of these agencies.

Richard: My perception is the small enterprise or the independent clinic owner may feel that larger entities perhaps, Sail closer to the wind or operate outside of what would be perceived as appropriate boundaries. But I believe it's quite the opposite. I think the larger the entity, the bigger the target on the back and the more compliant one has to be squeaky clean. What's your thoughts on this?

Tiffany: I would genuinely agree with that. I mean, it just makes sense. If you are running a bigger business and you have millions of dollars running through your coffers at any given time, you are going to be a target because they're gonna look at you.The volume of claims coming through to the payers, the volume of money coming through to the business from governmental payers. a larger footprint equals a larger amount of risk. And it is up to those larger organisations who have those resources to make sure that they have a program that appropriately assesses the risks and creates the necessary culture within the company to be compliant and ethical in all of their practices. So yeah, I would agree. Yes.

Richard: Now, obviously for small, independent private practices, they don't have the resources. For somebody like yourself, a clinical compliance officer, how would a small practice go about setting up a compliance program, would you say?

Tiffany: I would concentrate probably in three areas at first, but the first area I would say is review your contracts. You have to know what it is that you are obligated to. If you know what it is you're obligated to do, you can develop policies and procedures to compliantly get there. That's not only for CMS, which again, everything's published, you can go out and read it, but your commercial payers also publish their con, you have your contracts of course, but they also publish provider manuals. So it would behove practice owners to go and read those. Because their rules may be slightly different than Medicare. Essentially everybody's doing the same, but there are some differences in how you code and what documents are required and, and how you calculate your billable units. But ultimately, you need to know what it is that you are supposed to be doing. So that's the idea, number one, number two. I would get really, really up close and personal with HIPAA, the government publishes all kinds of information for HIPAA, you can go out to hipaa.gov, you can go out to any number of websites and read down the very basics of hipaa. It will outline all of your responsibilities in terms of safeguarding PHI from an administrative perspective, from a physical perspective and from a security perspective, because you have HIPAA privacy and you have HIPAA security obligations. I highly recommend that they take some time to go review that information and make sure that they know what their obligations are when it comes to handling phi and the third thing I would recommend is that they know their coding. Your diagnostic coding, your procedural coding, all of your coding needs to be tight. You've gotta make sure that you support the codes that you are billing in your documentation. If you are really sure, you take some time to just look at those three areas, what you have is a very solid foundation to build, to start building your compliance program up even at the smaller.

Richard: Yeah. It's not enough to just provide the care, is it? You have to document it in a specific way and also relate it to function and you know the why, so I think that trips up a lot of clinicians, doesn't it?

Tiffany: It does because there's a saying on the administrative side of medicine, and that is, if it's not documented, it's not. It was never done. And so you may think that you are putting your ideas down but what you have to do is you've gotta go through and make sure you're, you're checking some boxes and that the required information is there to support what you're doing. Because your biggest risk always comes from what you're putting out and what you're putting out are bills. You're putting out claims with codes on them. and then every once in a while you've gotta put out the documentation to support those, whether it be in an audit or whether it be just a regular part of the billing process for that payer.

Richard: What are the basic building blocks of a robust compliance program for a smaller entity? What do they need to focus on as it pertains to. Having a compliance program that they can show to a potential auditor.

Tiffany: The three areas that we just talked about I think are where you, you start, and then what I think where you take it from. There two important areas are, we talked about this education.There are pieces of education that are required on an annual basis. You have your frog waste infuse training, your HIPAA training, your civil rights training, and so on. These, these are areas to where you need to make sure that not only as a smaller business owner that, that you know what your obligations are, but that your other staff know what they are, because from your, from the time the patient walks into the door to the time the patient walks out of the door, There are rights that attached to them as a patient and you've gotta make sure that you are aware of what it is that you have to provide. If they do not speak English, you have to provide an interpreter. Sometimes you have to, just provide a service that allows them to receive the same level of care as anybody else that would walk in there that could do the things that they cannot do. So educating at the reg is something that private practice owners need to know, and then they need to make sure that their staff know. So educate, educate, educate. And then from, from that regulatory side of things, you go into, again, you address that billing and coding and documentation side. That's also important, but it's covered under that education section. Then the second thing, I guess it would be a total of five things here, is that you have to. So you have to take a look at what you're producing, what you're producing, what your staff is producing, and you have to make sure that it's within. We are required as healthcare providers to have a compliance plan in place, and part of any good compliance plan is that auditing function and whether it be a, a look at, at many different subjects, a look at how this code is used or, or how the goals are being formed, or what kind of prior medical history is being collected and documented in the medical record. Whether it's just something about just a general audit of a chart and you take a look at how they're performing from admission to discharge, whatever you can do is what you need. Whatever your resources are, you need, you need to be doing that.

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Richard: Welcome back to Agile&Me a Physical Therapy Leadership podcast. What tends to be a couple of common pitfalls that you've seen or often identified within the outpatient clinic setting that result in non-compliance.

Tiffany: I think one of the most common ones I see are a default to a certain. Coding methodology. That sounds a little bit more complicated than what it actually is, but I think what I sometimes see is that I see clinicians billing a certain code because they're comfortable that they know what that code means and they're comfortable that it's gonna be covered and paid. That's not the end of the story there, right? So it's gotta be, your coding has always got to match your clinical intent. And that's where with, with physical therapy especially that's where coding gets a little bit fuzzy because in a lot of other professions, what you have is you've got a code that means something and that's what it means, period. But with physical therapy, you use a code based on your clinical intent. So the same thing that you do with one patient, you can do it with another patient. But have, but have a completely different intent, maybe at a functional level or a neuromuscular level. You've got to, you've gotta take into account what your intent is so that's one of the biggest items that I see is that we fall back into using codes that, again, we're comfortable with. They're commonly used and, but they don't really reflect what it is that we're doing within that treatment session with the patient. The other one is knowing the rules of the player that you're dealing with and this is a lot of times a little bit more of an administrative issue because it deals, when you're looking at a payer's rule set, you're really looking at how they want you to code and how they want you to accumulate units and how they want you to bill. But therapists have to be aware of this as well because it affects how they track their time and how they calculate their units and how they schedule their patient. There's so many ripple effects out there from this particular area. It's just something that I feel really strongly that clinicians should be educated on, and that is that, there are two ways to calculate units and certain payers follow this and certain payers follow that. So the more aware they are of that, the more compliant that they can bill and code and document.

Richard: It's amazing. I think the amount of dollars that are left on the table for the work that clinicians do, but they just don't bill in the appropriate manner for the specific payer, and we are just giving away care and time, aren't we as a profession? It's remarkable. If we move to looking forwards, how has the Covid pandemic changed the compliance landscape to this point?

Tiffany: Covid has really brought the subject of infection control into the picture and with an outpatient clinic we're a physical therapy outpatient company. When we look at what our obligations are from an infection control standpoint, we all know that we've gotta clean the table, we've gotta clean the equipment, we've gotta do this and that. But, what Covid brought in was a little bit more of an awareness of how we do that and the extent to which we do that, and then also how we interact with our patients as they come into the clinic. So we have to deal with the fact that we've gotta screen the patients and we've got to document that we screen the patients. So we have to have a processing policy in place, and then we have to continually keep them spaced apart. You're six feet apart and you've gotta make sure that they're wearing a mask. That you're cleaning anything that they touch in between and you are washing our hands and doing all of these things that we all washed our hands before covid right? And we cleaned the equipment before Covid, but, but, I think the pandemic has made it a little bit, it's made us all a little bit more cognizant of the fact that infection control practices do exist. And guess what? They exist in a physical therapy office. I view this as positive. This is an area where it might, you know what I'm about to say? Might be a little bit controversial, but I had experience with PTs in the past saying that, well, we're just a physical therapy clinic. But on the other hand they argue that, oh, we're medical professionals. We are experts in body mechanics and movement. You gotta pick a quarter and you have to decide from what corner you're gonna start your argument and how you're gonna build that out. I think with covid, with us having to undergo the same infection control practices and screening practices and us, we were declared essential workers. We were never really shut down. That's great because I think people will remember the fact that, oh, look, they were a medical provider and they were never shut down either. We're not just physical therapists. We provide an essential service, we provide a medical service, a necessary service to our patients. And I think that helped our providers realise that they're just physical therapists. They are a full on partner in the medical field, treating patients alongside the doctors, and that is a positive for me. The other thing I think is that it sets some new rules. Again, I go back to you having to know what it is that you're supposed to do, and in the area of outpatient practice, you had some rules that dealt with infection control and worker safety standards and health standards, but they weren't cohesive. And now what I see is that there's this, there's this rule set that's coming together and it is becoming cohesive. I think it's here to stay, but we know what we now have to do in terms of infection control and keeping our patients safe and keeping our staff safe. Not just through Covid, but through cold season, through flu season, through anything else that may pop up that, where we have to go back to these.

Richard: There's been a monumental shift as it pertains to telehealth services and therapy. Can you just give us your insight as to what changed and what you think will happen in the future as it pertains to telehealth and therapy service?

Tiffany: Sure. I think if I can have a favourite part of the pandemic, I think my favourite part would be where we had more access to our patients and our patients had more access to us, and I think that's always a good thing. with telehealth. We had a lot of, you know, we had 50 states, 50 different sets of rules as to who could do it, how they could do it, whether it was synchronous or asynchronous transmission. So many rules, what codes could be used, what we can do, what we cannot do. And so I think that with telehealth I was really, first we went back and forth about who could do it and what payers would pay for it and whether patients would benefit from it. But I think within just the first few months, our profession and the medical prof, you know, the medical field in general, determined that, hey, this is a valid way that we can access our patients safely. I think it's here too. We are seeing some movement on the private payer side or the commercial payer side where they are putting telehealth as a permanent benefit to their patients. So that's always a plus. We haven't seen CMS do that yet. That was a little bit disappointing because that was a quest this year that unfortunately did not make it into the final rule. The other positive I see is increased access via direct access. With physical therapy, a lot of times you have to have a script. There are states that are wide open that say you can see a physical therapist for anything as long as you want. And there are states that say, well, you can see this p this physical therapist, but you know, you've gotta have, you gotta go right back to your doctor and tell 'em why you saw 'em and get a script and take it back and then it'll be covered. So I think with, with covid. What we had was a little bit of a movement forward in how patients can access us, and we actually have seen movement in the direct access laws in about seven different states.

Richard: Yes. I never thought I'd hear somebody say they had a favourite part of the pandemic , so congratulations on that. But I would certainly agree with the idea that Covid has been a catalyst of change. I think change was occurring, but it certainly allowed a paradigm shift to occur rather than this. Small drip drip of change that has, that has been occurring over an extended period of time, hasn't it?

Tiffany: Absolutely. Mm-hmm.

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Richard: Welcome back to Agile &Me, a Physical Therapy Leadership podcast. How do you see the regulatory landscape changing in the future? I tend to see further regulatory requirements. I would, I hope that you can say something different than that, but what's your perception as it pertains to the regulatory landscape?

Tiffany: So two things come to mind strictly from an administrative standpoint, and that is the movement, again, towards direct access, but as an offshoot. What had been proposed to CMS was that we relieved some of the administrative burden on PTs. We have clinicians that are educated at this point to the doctoral level, and why on earth do we need a signature on a plan of care for a patient that was either referred to us or decided they came to see us? If we are the experts, In movement, in body mechanics and, you know, if we can contribute without pharmaceutical intervention, with pain management practices with our patients. Why do we need that additional level? Why do we need that administrative burden there? So I, we are looking at possibly having that it's, it's a dream really from a compliance perspective because it's one less thing we have to worry about. But to have that requirement for people that are accessing us with a prescription. To no longer have to have that signed plan of care. So I look at them as relieving that administrative burden. The other administrative burden that I'm seeing trying to go away is the idea of these rules that govern what we can do and what we can't do during a session that we can or cannot build together. And I won't bore anybody and go into my soapbox speech but what we're seeing is we're seeing a movement to relieve us of the burden of having to add additional modifiers to codes when we are trying to document our care for this patient and having to build these codes in a certain way, or append this or that after the fact. We need to be focused on treating our patients and we need to be focused on documenting what we are doing with them. We do not need this extra. Administrative burden of, well, let's get this signed, even though we're never really gonna ask you for it unless, unless there's an audit, or, let's try and, and bill our codes this way and, and put all of these modifiers on there. There's just no reason for.

Richard: I always feel as a clinician that we're almost trying to be tripped up to prevent payment. I admittedly, I'm a firm believer that one needs to document appropriately and accurately that, you know, even with that sometimes it still doesn't, isn't sufficient for certain payers. I definitely agree that the signature component and the modifier codes would be huge moves forwards for the clinic.

Tiffany: I agree. I think the other side of that, on the patient side of what we're looking at moving forward are there are going to be more rights allocated to the patient. I don't know if you've read it, but I've read the proposed rule to update HIPAA and what these rules are doing is they're shifting the power to the patient Right now. HIPAA does a great job, I think. Requiring providers to provide records and the like, and, and protect the information of, of its patients. But they want to move that forward because again, this is under the OCR, the Office of Civil Rights. So privacy is, think about that. It's governed under the Office of Civil Rights that deals with our privacy. And so what they're doing is they're shifting the rights away from the provider to the patient.

Richard: Before we finish up, I would love any final thoughts or advice for our listeners as it pertains to kind of compliance issues at the current time.

Tiffany: My final thought would be we've talked about knowing what you, what your obligations are, and once you do that, if you see a problem, address it. Half the problem is, When you address it, and one of the things that some of these regulatory agencies look at is, okay, they found a problem. Now what did they do? This is where they're focusing their attention. What did you do after you found out that that was a problem? And they want to see that the company, big or small, made a good faith effort. To resolve whatever issue, reared its head in that particular incident. So if you have a problem, if you see a problem, address the problem, make a good faith effort to correct it and document what you've done. And, keep, keep a record of these things because ultimately as a small practice owner, you are going to be responsible for what happens within that company.And again, half your battle is one, once you address it, effect. and I just couldn't recommend any more than that.

Richard: Tiffany for your time today. I've really appreciated talking to you and learning a little bit more about compliance and what a clinical compliance officer does, and I'm sure that the listeners appreciated as well. This was brought to you by Alliance Physical Therapy Partners in Agile virtual Care. For more information, please visit our websites AlliancePTP.com