Automated Billing Systems and Compliance - Column

Health Management Technology, August, 2001 by Leah Curtin, Roy L. Simpson

Nurses must become knowledgeable about software systems that can and cannot help eliminate errors.

One of my favorite books in the whole world is Laura Nash's Good Intentions Aside: A Manager's Guide to Resolving Ethical Problems (Harvard University Press, Boston, 1990).

In thumbing through the book a few days ago, I came upon a subsection entitled, "The Ethical Implications of a Bottom-line Orientation." Mind you, this woman has not, insofar as I know, worked, consulted or even written for healthcare executives. No, indeed! Her work is directed toward the average business executive.

What does she have to say about a bottom-line orientation? "... when profit becomes the dominant purpose, it is not just prioritized, it is `exclusified.' Profit is so concrete and `strong' a claim, and ethics so abstract and process-oriented that the former [profit] easily gains dominance over the latter [ethics] in decision-making." Do tell.

Now wait, she gets better. "The potential moral limitations of adopting a superordinate bottomline orientation," Nash writes, "can be summarized in two Farts: It leads to a restriction of a manager's definition of goals, and to an indifference to the means by which these goals are achieved.... When a superior invokes the bottom-line as the single most important performance goal, other goals such as value creation and integrity have about as much lasting power as a snowflake on a hot rock." Oh, pinch me or I'll think I am dreaming.

Yep. I double-checked the masthead--this book was published by "The President and Fellows of Harvard College" home of the Harvard School of Business and the Harvard Business Review--Mecca of the revisionist restructuring of hospitals in the 1990s. I chortled, "Yes. YES, YES!" as I continued reading this excellent commentary, thus causing some raised eyebrows in nearby offices.

"Some managers invoke a survival scenario to motivate a more urgent winning attitude, but in doing so, they dig an even deeper profit-dominated hole for employees to fall into. When the bottomline is the overriding goal, the needs of others, including customers, are lost and the rules bent.... This bottom-line pre-occupation net only emphasizes the achievement of economic success to the suppression of other important goals, it also undermines the moral norms regulating the means to success.... Moral obligations such as honesty or reliability are excised for the sake of success.... The moral fallout from such rationalization can be as small as tampering with the taste of a brand name, or as deadly as the failure to correct defects in a brake design."

In the five-year period from 1994 to 1999, criminal convictions for healthcare fraud increased more than fourfold thanks to the government's and media's increased attention to the problem. These days, healthcare organizations are scrambling for ways to eliminate any billing and reimbursement errors--intentional or unintentional--that the government may label fraudulent.

The emerging role of the compliance officer provides nurses both with a new career opportunity and an outlet for combating fraud. But to do it, nurses must understand automated billing systems and their role in ensuring compliance.

Certain types of financial information systems are more susceptible to misuse than others. Here is a rundown and what nursing can do to help reduce that misuse:

Basic software--designed for general use, limited customization. The greatest potential for claims errors lies in the data entry process. Nurses and nursing managers who routinely generate source documentation need to be especially aware of this and implement policies to ensure accuracy.

Informational software--uses internal databases of information (such as dictionaries of diagnostic codes) to minimize data entry errors. The problem is some databases may be manipulated to facilitate intentional misuse. Nursing should endorse the use of such controls as passwords to prevent unauthorized system changes.

Interactive software--uses databases and dictionaries as checkpoints, but also lets users correct software-detected problems during data entry. To ensure the most comprehensive system of checks and balances, nursing should work with IS to ensure that billing systems access the entire database rather than just those codes in a "favorites" list.

Proprietary software--designed for a particular user or group of users. This specialized software could be intentionally designed to produce inaccurate or fraudulent claims.

Nursing should take the lead position in alerting the organization to coding options that direct claims decisions toward procedure codes with higher-valued reimbursements.

Industry experts predict that the government's scrutiny of healthcare billing practices will not only increase, but reach to physicians in private and group practice, and by default, to nurses--especially advanced practice nurses (APNs). The subsequent creation of procedural codes for APN interventions has removed the veil of invisibility surrounding nursing, making accuracy in coding a personal issue for nursing. Understanding what systems can and cannot do to help is the key to resolving this issue.