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Medicare Compliance - Mark Pastin
Medicare Compliance - Mark Pastin

Mark Pastin
Chair and President of the Council of Ethical Organizations, Mark Pastin has advised major corporations and government bodies worldwide since 1973. His book The Hard Problems of Management; Gaining the Ethics Edge (Jossey-Bass: 1986; NTT Publications-Japan: 1994) has won awards in the United States, Brazil, Australia and Japan. Dr. Pastin has authored over 100 articles and books.

Dr. Pastin has advised corporations including Caterpillar, American Express, Medtronic, NYNEX, Blood Systems, Inc., Motorola, General Electric, Texas Instruments, Intel, Cadbury Schweppes, Allied Signal, J.P. Morgan, and GTE Telops. Dr. Pastin has served as advisor to both Houses of Congress and to state and federal agencies. U.S. agencies served include the Internal Revenue Service, the Social Security Administration, and the National Science Foundation. Foreign governments and agencies include the European community, the Federal Government of Brazil, Mexico (President's Commission on housing), Australia, Hong Kong (Anti-Corruption Commission), the Republic of China, and the United Kingdom.

Dr. Pastin received his B.A. (summa cum laude) from the University of Pittsburgh and his Ph.D. from Harvard University (Lewis Award). He has served as faculty member and administrator at Indiana University, the University of Michigan, Harvard University, University of Maryland, and Arizona State University. Dr. Pastin has also served as Research Fellow of the Center for Metropolitan Planning and Research at Johns Hopkins.

Dr. Pastin serves on several corporate and non-profit boards. He is recognized in Who's Who in America, Who's Who in Finance and Industry and Who's Who in the World.

Mark Pastin, President
Council of Ethical Organizations/Health Ethics Trust
214 South Payne Street
Alexandria, VA 22314
Tel: 703-683-7916, Fax: 703-299-8836, email

Question 1 - Mark, What is the one area you continue to see organizations needing to improve in medicare compliance? And what suggestions might you have for improving in that area. by tammy on February 7, 2000

Answer 1 - Organizations are failing to provide workable input mechanisms for their employees - and are being punished with False Claims filings running to the hundreds of millions of dollars. While the time invested in actually speaking to your own employees may seem like a huge investment, it is not even a measurable dollar amount as a perentage of the claims being settled today. The second area of needed improvement is in antiquated and decentralized billing systems. Mark Pastin by Mark Pastin on February 7, 2000
Question 2 - Will the HIPAA regulations accelerate the movement toward improving the old and decentralized billing systems? Possibly increasing compliance as more processes become standardized? by yvette on February 8, 2000

Answer 2 - The HIPAA regulations certainly increase the incentive to modernize hospital IT systems since there are high per incident penalties associated with privacy violations (pending approval which is nearly certain). But the move to centralization is likely to remain slow until leadership resolves billing and IT turf wars and until the providers demands better solutions from IT vendors. Most of the "system compliance solutions" currently available are patches on existing systems that often create compliance problems. by Mark Pastin on February 8, 2000
Question 3 - With changes in home health reimbursement, many agencies find their volume of medicare visits has decreased. What do you suggest to keep compliance in the forefront of the organization if senior leadership still considers compliance "a medicare issue"? by FaithE on February 8, 2000

Answer 3 - It is important to understand that private payers have powers modeled on those of the federal government under HIPAA - and they are learning to use those powers. Medicaid anti-fraud units are getting more skilled and more aggressive. In the end, the most compelling argument to senior managers in smaller organizations is that, if there a problem, they will be on the hook - period. by Mark Pastin on February 8, 2000
Question 4 - What strategies would you advise in handling APCs? What resources are available for this? by Luke on February 9, 2000

Answer 4 - Heck of a good question. APCs are Ambulatory Payment Classifications (formerly APGs) and I most familiar with ER related problems. The hospital's billing now depends on the ER physicians documentation, which follows a different protocol - sign and symptom for one and not the other. This in turn may negatively impact the hosp and create external audit flags. I know of experts in this area (Ed Gaines) but no quick fix solution that does not require a cooperative protocol (compliance, originating physician, and both billing funtions). Mark Pastin by Mark Pastin on February 9, 2000
Question 5 - I recently went to a Medicare seminar...the presenter made the comment that "The question isn't if an audit will occur but, when." Do you think that even proactive compliance measures will be futile as far as staving off the "hounds of Medicare".
John by Biller on February 9, 2000

Answer 5 - Well, your presenter is engaging in all too common practice these days - trying to scare audiences into buying services. Even if you are audited at some level, a good compliance program will really help. The purpose of even the best compliance program is not to reduce errors to zero - that is impossible. The purpose is to isolate errors so that they are not patterned and so that an auditor will readily see that your organization is trying to find and resolve errors. I know of few organizations with solid compliance programs that can not withstand a routine audit. by Mark Pastin on February 9, 2000
Question 6 - In regards to question #4: With hospital reimbursement declining what steps can hospitals take to consolidate their medical records regarding APCs. Do you know of organizatons who are doing this well? by Artemis on February 9, 2000

Answer 6 - Well, I know of some that are making progress. Healthcare Business Resources, a billing company in Durham, NC is working with hospital clients on this issue and is at the cutting edge. Tenet Healthcare headquartered in Santa Barbara will also get a jump on this one. But Forum participants may have others to commend and this is certainly welcome. by Mark Pastin on February 9, 2000
Question 7 - Some compliance programs incorporate an internal "hotline" for employees to report infractions. However, employees are concerned with maintaining their anonymity. What are your suggestions for overcoming this obstacle? by Terin on February 10, 2000

Answere 7 - This is the hardest problem in implementing the hotline. Even if employees remain anonymnous on the call, their identity may be uncovered during follow up. The right strategy is to blind the line to caller ID, clearly state an anonymity policy, and explain exactly how the process works in your training. We publish a handbook on this topic that provides most of the details ( You must publish and enforce a non-retaliation policy as well - emphasis on enforce. by Mark Pastin on February 10, 2000
Question 8 - With the graying of America moving steadily upward in numbers, changes in long-term health care options are necessary. But because money issues for assisted living or nursing homes is becoming a major problem, how can the administration and caregivers keep up? They have demands made on them by OSHA, GOA and Compliance issues, and following all these numerous regulations is definitely damaging their profit margins. Can you give any feedback on how nursing homes or assisted care facilities are managing compliance with federal, state and local legislation while not reducing the level of staffing? This is an area that usually gets cut when administrators look at budgets, and when staffing is cut, instead of saving money in the long run, the facility is really hurting itself quite a bit. What are your opinions on the balancing act? by Ingolfsson on February 10, 2000

Answer 8 - As you know, long term care facilities are not coping with these pressures too well. The number of bankruptcies speaks to this point. But compliance is not the problem. While some facilities use financial pressures to avoid fielding a first class compliance effort, a good compliance effort is revenue neutral - at worst - assuming you are running an honest operation. Compliance is not an additional burden but an integrated approach to all of the legal and regulatory requirements that are burdening facilities. However, I could not agree more that staffing is a major issue and that in most cases there is nothing left to cut - a tragedy in many cases for the patient and care giver. by Mark Pastin on February 10, 2000
Question 9 - Are there any circumstances in which an advanced practice nurse may bill for services he/she delivers in a hospital based outpatient clinic? In an academic medical center, if the salary of an APN is paid from an entity other than the hospital--such as a school of nursing or school of medicine, can the APN bill for services? Under this scenario, can a bill be submitted for "incident to" services. Can "incident to" guidelines differ between payors without creating a compliance issue with Medicare? SC by scooper on February 11, 2000

Answer 9 - This is too technical a question for me to answer personally. A quick answer is that I do not think you can bill "incident to" in this context (hosptial owned clinic). With respect to the second part of your question, I think you are asking if incident to quidelines can vary between medicare corriers/FIs without compliance issues. teh answer to this question is, It depends. HCFA allows carriers to set guidelines in some areas but not others. Generally, if you note an inconsistency, you must seek clarification from the payor being billed before submitting. Technical billing questions are often addressed to our list serve (Talk-About-Compliance) - You can enroll at no charge at Thanks by Mark Pastin on February 11, 2000

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