Physicians and compliance: developing a system that works

This article will describe the development of a method to educate physicians and other health-care providers about the components of the Model Compliance Plan for Clinical Laboratories. It incorporates adult learning principles through the use of academic detailing and other educational tools. The improvement process and indicator data used by our health-care facility is outlined. Since the release of the Model Compliance Plan for Clinical Laboratories in 1997, it has been an ongoing challenge to meet its guidelines and develop processes to ensure compliance of medical necessity documentation and submission of accurate claims for Medicare reimbursement. Most laboratories have the appropriate policies and procedures in place to achieve effective compliance programs. However, the existence of a policy does not ensure compliance. In our organization, Mercy Medical Center-North Iowa, Mason City, Iowa, baseline data demonstrated the need for process improvement in the area of physician office compliance. Often, advance beneficiary notices or notices of non-coverage were nonexistent or incomplete; medical necessity documentation for the requested tests was inconsistent; and patient demographic information was incomplete. As a result, Medicare could not be billed and laboratory write-offs were at an unacceptable level. We will outline some of the compliance issues currently facing laboratories and describe the systems approach used to improve physician compliance in our system.