Staff Spotlight

“Most physicians here don’t realize how lucky Yale is to have somebody of Judy’s caliber,” said Joshua Copel, MD, medical director of billing compliance. “She was on the other side of the audit table before she came to Yale, so she knows what’s going on in the minds of the auditors and she can give us very valuable advice.”

Harris came to Yale Medical Group after overseeing medical review and fraud and abuse activities under Medicare contract in 16 different states for Aetna, Travelers and Connecticare. She participated in a government technical advisory group that was instrumental in setting guidelines used today—a group that she now believes “should have had providers at the table.”

She was hired by Yale Medical Group to create one of the first compliance programs in the country. “We have the cornerstones of any compliance program, including physician training, internal audits and a hotline,” said Harris, who oversees seven auditors covering 18 clinical departments. “My auditors are constantly answering questions. I take that as a sign that people are comfortable coming to us with questions,” she said.

This work is especially complex in a large practice; in 2010, Yale Medical Group billed out a total of 2,068,682 services, including 687,000 services to Medicare alone. As medicine advances, current procedural terminology (CPT) codes change on an annual basis, diagnosis codes change twice a year and government regulations can change at any time. There are special regulations concerning a physician seeing a patient in conjunction with a nurse practitioner or a physician assistant, and documentation is required if a physician is caring for a patient while acting in a teaching capacity with a medical student or resident.

The job of ensuring that bills are accurate can call for creativity, as, for instance, when a physician performs a groundbreaking new surgery that doesn’t have a CPT code. Harris and her staff have contacted the American Medical Association for input as they determine the best way to categorize a procedure.

“It takes a lot of reading to keep up with it,” said Jennie Oddy, a senior compliance auditor who has worked with Harris for 11 years. It helps that the staff works well together. “Judy is always encouraging teamwork, and because of this, we really do have a great team here. We enjoy doing a lot of brainstorming. If we have a strong opinion, we feel comfortable to speak up.” While each auditor has his or her assigned departments, it’s common for everyone to pitch in and tackle a particularly difficult task together, she said.

The department double-checks its own billing by performing internal audits. At the beginning of each year, compliance auditors determine the areas of highest risk—often the practices with the highest billing and, as a result, the greatest potential for a billing error. “In a typical audit, we pick 10 patients who we have billed in a three-month period, pull the patient medical records and compare what has been documented with what was billed, checking for the correct coding and documentation to support the services,” Harris said.

External audits are even more time-consuming and are becoming more frequent since the 2010 Patient Protection and Affordable Care law which added more audits and enforcement to combat Medicare fraud and errors and expanded the role of recovery audit contractors to include pursuit of improper payments on Medicaid claims. “Last year, we spent 46 percent of our time responding to external audits, and we expect to see that increase,” Harris said.

When Medicare audits Yale Medical Group, they may look at 25 practices and review 100 claims from each practice. The auditor will give Harris’ team names of patients and date ranges and ask for records. “Judy has been especially aggressive at following up on the findings of the new auditors and reviewing every single comment they make,” said Dr. Copel.

The complexity of this work can make misinterpretations and even mistakes unavoidable, so Harris has free access to the services of Deputy General Counsel Susan Carney and attorney David Florin in Yale’s Office of the Vice President and General Counsel. She lets them know when an audit involves significant dollars and seeks their input on correspondence with public and private insurers. In addition, Harris directs two compliance committees, meeting with each on a quarterly basis. They include the high-level Medical Billing Compliance Committee, which includes representatives from the Office of the Vice President and General Counsel and the Office of the Provost; and the Billing Compliance Leadership Committee, which includes an administrator and senior physician appointed by Harris from each department.

While it sometimes seems as though Harris spends the bulk of her time with auditing, she is passionate about battling health care fraud. Last November, she was delighted to be invited to sit on a panel at the Health Care Fraud Prevention Summit at Brooklyn Law School hosted by U.S. Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sebelius, who are leading President Barack Obama’s initiative to eliminate Medicare fraud.

Joining such experts as a Columbia University College of Physicians and Surgeons professor and the director of the National Insurance Crime Bureau, she delivered a twofold message: first, organizations must establish “an atmosphere of compliance,” and second, it’s time for government to perceive health care providers as partners instead of bombarding them with an overwhelming collection of byzantine rules, regulations and audits.

The billing world as a whole has become too complicated, putting physicians at risk for making mistakes, Harris told her audience. Specifically, she challenged current documentation guidelines for hospital and office visits that require providers to tally up as many as 101 different components of a visit to complete the bill. “Personally, I would rather have my physician concentrating on my medical issues than on making sure he or she documents every component of the visit in order to bill at the correct level,” she said.

“For me, going to the summit at Brooklyn Law School was a fairly gutsy thing to do,” she said. Peter Budetti, deputy administrator for program integrity at the Centers for Medicare and Medicaid Services (CMS), was the facilitator of the panel. “I gave him some challenging information. But in the end he said that he appreciated what I said, and he said that the CMS absolutely needs to hear these types of comments,” Harris said.

If she could send one message to Yale Medical Group physicians, Harris would remind them that her group works for them. “I’d like providers to know that we are on their side, that we recognize the challenges they face in a complex environment and that we want to do everything we can to help them,” she said.