General Surgery Coding Alert - 2010 Issue 4
PHYSICIAN PRACTICE: Risk Managers to Physicians: 3 Strategies Keep Your Practice in the Safety Zone
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Article Overview
This article is aimed at physicians, practice managers, and risk/compliance professionals who want to understand how to review practice patterns for safety, audit readiness, and consistency with broader clinical expectations. It covers general risk-management guidance on using specialty guidelines, identifying and explaining outlier patterns, and comparing care across patient groups and payers. The focus is on avoiding unnecessary scrutiny by being able to support legitimate clinical reasoning and understand how utilization patterns may be viewed by auditors and government agencies.
Why This Topic Matters
Practice patterns can attract attention from auditors, payers, and government agencies when they appear outside expected norms. Understanding how to evaluate and explain those patterns helps practices reduce compliance, reputational, and malpractice risk.
Article Sections
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Introduction
Introduces the concern over utilization patterns and the need for physicians to assess how their practice compares with broader standards. It frames the topic around compliance, peer comparison, and risk management.
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3 Ways to Stay Problem Free
Outlines three general strategies for reviewing practice behavior and responding to scrutiny. The section centers on benchmarking, identifying outliers, and considering payer-related differences.
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Use specialty practice guidelines as a benchmark
Discusses the role of specialty clinical practice guidelines as a reference point for assessing care patterns. It emphasizes comparing current practice with recognized professional standards.
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Examine and explain outlier practices
Addresses how to evaluate physicians whose patterns differ from peers and the kinds of broad factors that may account for variation. It also touches on how differing clinical viewpoints can affect practice patterns.
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Compare care for different populations with the same conditions
Reviews the importance of looking at differences in care across patient groups and payers. It highlights the relevance of preauthorization and reimbursement-related variation as risk areas.
What You Will Learn
- How physicians can compare practice patterns with specialty guidelines and peer norms
- Why outlier utilization patterns may warrant internal review
- How differences among patient populations and payers can affect perceived practice variation
- What kinds of risk management concerns may arise when practices fall outside expected norms
Who Should Read This
- Physicians
- Physician practice groups
- Practice managers
- Compliance professionals
- Risk managers
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