E/M Coding Alert - 2010 Issue 3
HOSPITAL RISK MANAGEMENT: Head Off the Specter of Surgeons Performing Unneeded Procedures
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Article Overview
This article is aimed at hospital administrators, compliance staff, and coding or revenue integrity professionals who need to understand how facilities can spot and respond to potential concerns about medically unnecessary procedures. It covers general risk-management and oversight strategies, including monitoring procedure growth, reviewing practice patterns, investigating complaints, and auditing documentation and coverage-related records. The piece is relevant to organizations managing physician activity, patient safety, compliance exposure, and medical necessity concerns.
Why This Topic Matters
Hospitals can face legal, financial, and reputational risk when allegations arise that procedures performed by affiliated physicians were unnecessary. The article highlights why early detection and routine oversight matter for protecting patients, reducing liability, and limiting downstream compliance problems.
Article Sections
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Beware: This Isn't the First Case
Provides background on reported situations involving concern about unnecessary procedures and the broader compliance environment in which such issues may surface.
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4 Ways Hospitals Can Protect Themselves
Outlines broad hospital oversight and monitoring approaches designed to help identify potential red flags and support internal review.
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Examine a surge in big-ticket procedures
Discusses monitoring changes in procedure volume and related quality assurance activity as a way to spot unusual patterns.
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Flag physician practice patterns that seem out of whack
Focuses on comparing physician activity patterns and recognizing when utilization appears unusual within a service line.
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Investigate any complaints or concerns
Covers the importance of promptly reviewing allegations or concerns using appropriate internal or external oversight resources.
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Audit surgical procedure documentation for medical necessity on a routine basis
Addresses routine documentation review and medical necessity oversight as part of compliance and payer-focused monitoring.
What You Will Learn
- How hospitals can monitor procedure trends for potential compliance concerns.
- How physician practice patterns may be reviewed for unusual activity.
- How complaints and allegations should be evaluated within a hospital setting.
- How routine documentation audits support medical necessity oversight.
Who Should Read This
- Hospital administrators
- Compliance professionals
- Coding managers
- Revenue integrity staff
- Risk management personnel
- Clinical documentation reviewers
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