In a recent presentation at the VEITHsymposium 2023 (14–18 November, New York, USA), Terry Litchfield (president, Access Solutions) outlined what she believes to be the key factors for ensuring effective compliance for vascular access providers.
The first thing that must be done, according to Litchfield, is “[…] a culture of compliance.” The way to do this, she stated, is via the seven major elements of compliance: implementing written policies, procedures and standards of conduct; designating a compliance officer and compliance committee; conducting effective training and education; developing effective lines of communication; conducting internal monitoring and auditing; enforcing standards through well-publicised disciplinary guidelines; responding promptly to detected offenses and undertaking corrective action. It is these seven key elements that Litchfield feels are essential to ensuring that a practice stays compliant to Office of Inspector General (OIG) guidelines.
“You [need to] have written policies and procedures”, she continued. “You have a compliance officer—for small practices these do not need to be full-time jobs, and if you really feel like you have some risk, there are companies that can sub-contract you a compliance officer. You have to educate and train your staff that, if they see something, they need to say something. You have to have open lines of communication. That is why we hear hotlines and hotline services; you have to do internal monitoring and auditing.” It is also important, Litchfield added, that guidelines are followed. “There are guidelines and there are well-publicised local coverage decisions and national coverage decisions”, so she feels that they must be followed, and that “all procedures meet the guidelines, and it is important to document in your electronic health record system.” The final of the seven points that she highlights is the importance of transparency and taking the necessary action to resolve issues. “You need to respond very quickly if you feel that something has happened and corrective action is needed.”
Other aspects that Litchfield chose to focus on during her presentation were the importance of written referrals and documenting the medical necessity for procedures. “The first thing that is important,” she stated, “is medical necessity for angiogram and angioplasty, and to make sure that you study the guidelines.” These guidelines, she says, will clearly describe medical necessity for these procedures, and it is vital that they are all met. The other side of this is ensuring that all of these requirements are documented in the electronic health record (EHR) system, which is where the importance of a written referral comes in. She explained: “Any auditor that comes out from any government agency, the first thing they ask for is the order and anybody can look at the Medicare billing guideline. It must be a signed order. So, it is really important that your front desk know they can take a verbal order, but at some time […] within the next 10 days, [they must] get the nurse practitioner who does rounds with the dialysis units to come and sign that order.”
Continuing from these points, Litchfield moved on to what she referred to as “the most important slide” of her presentation; what not to do. The slide focussed on one key point; “When a patient leaves, do not schedule future procedures. One of the things that the OIG analytic team has the ability to do is they can get a download of your scheduling software. So if you say, well, no, we did not schedule this in advance, they can actually subpoena the software programme and see that the angioplasty for December 1—the appointment was made October 1.” The correct procedure for booking a follow-up appointment, as Litchfield states, would be to first request the patient return for a post-op office visit, and, should an abnormality be detected, a diagnostic test— that is the angiogram—and then other subsequent interventions can be performed.
Drawing her presentation to a close, Litchfield summarised the key points that she feels that are at the core of compliance for vascular access; “remember; valid orders, a good history, a physical exam. All documented well.” She also added that it is vital have as much information in your histories and documentation as possible, and that if you retain all radiographic images, clone notes and “make sure that your history, your physical exam, and your clinical judgement is in your operative notes,” you can make your records “tell the story” of a patients’ treatment—thereby making sure that any auditor can see exactly who a procedure has taken place.
