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American Academy of Emergency Medicine

AAEM Urges OIG To Include Open Books Language in Proposed Compliance Program

AAEM, in continuation of its mission to represent the interests of the working emergency physician, has written to HCFA's Office of the Inspector General, urging the inclusion of language protecting the rights of EPs to see what is billed and collected on their behalf in a proposed compliance program for individual physicians and small group practices. The letter, dated October 15, 1999, reads as follows:

To Whom It May Concern:

The American Academy of Emergency Medicine (AAEM) is appreciative of the opportunity to provide information and recommendations regarding the proposed OIG Compliance Guidance Program for Individual Physicians and Small Group Practices. AAEM is a specialty society representing approximately 2,500 emergency physicians. A central element of our organization's mission is to ensure a fair work environment for the individual emergency physician. AAEM acknowledges the presence of significant concerns for fraud and abuse in the specialty of Emergency Medicine in light of recent high profile judgments related to Emergency Medicine billing firms.1 Consequently, we hope that the OIG will evaluate our recommendations carefully. They are as follows:

  1. A compliance program must ensure that individual physicians are provided with regular, accurate, and verifiable accounts of what is billed and collected related to the professional services they render. We recommend that a copy of all statements regarding claims made and paid on behalf of a physician be sent directly to the physician. Additionally, we recommend that a copy of the end of the year 1099 for all payors be sent directly to each physician. This information should be provided without requiring the physician to submit a request for this information. The physician should be afforded the opportunity to review upon request the coding and billing procedures related to their work situation.

    Rationale: The individual physicians cannot fulfill their intended role as a check on fraud and abuse without the above information. In the field of Emergency Medicine individual physicians working as independent contractors are routinely denied access to this information. Unfortunately, the same circumstance also occurs with some small group physician practices. In small group practices such information is frequently only available to one or few senior "partners" who control ownership of the practice. Physicians who request such information may be subject to termination or threats thereof. It is of great concern to AAEM that, because of this, emergency physicians are placed in a precarious position related to unwitting involvement in upcoding or other fraudulent activities. Additionally, the inability of the physician to review the remittances made on their behalf exposes them to potential involvement in prohibited fee-splitting activities.

  2. A compliance program should clearly delineate the methods for physicians to report situations in which they believe violations may be present. Phone numbers of the appropriate agency should be included. This process should be as confidential as possible.

    Rationale: Currently, the individual physicians lack the knowledge of how to report violations, creating a barrier to their taking action. Given the risk of job loss, assurances of confidentiality will be necessary to facilitate such reporting.

  3. The OIG should consider creating a compliance guidance program for large physician groups or extending this guideline to include such groups.

    Rationale: A growing number of physicians are practicing in large groups as a result of the emergence of physician practice management firms and the trends towards consolidation of smaller groups into large practices. In these circumstances, the individual physician may be further removed from the billing and coding operations yet retain the same risks for involvement in prohibited activities. This situation is particularly acute in Emergency Medicine where large for-profit physician practice management firms are a dominant form of employment. Currently, the three largest firms employ approximately 30% of the practicing emergency physicians. These physicians are routinely denied access to information related to billing and remittances made on their behalf.

AAEM would be happy to provide the OIG with further information or support of the above items. We may be contacted at 1-800-884-AAEM. Thank you again for this opportunity to provide input into this proposal.

Sincerely,

Robert M. McNamara, M.D., FAAEM
President, AAEM

Reference

1. United States ex rel. Semtner v. Emergency Physicians Billing Services, No. Civ-94-617-(C) (W.D. OK).