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February 27, 2012

Ethical Business Practices in Transcription
By Elizabeth S. Roop
For The Record
Vol. 24 No. 4 P. 10

Medical transcription is a $12 billion industry responsible for nearly 60% of the 1.2 billion clinical documents produced annually in the United States. Yet despite its size and impact, for years it was left to its own devices in terms of policing its ranks for unethical business practices. From a lack of industry standards governing line count definitions to few (if any) regulations holding transcription companies liable for inaccurate or altered data, it was an industry ripe for fraudulent behaviors.

All that has changed within the past decade, driven by a confluence of events that is transforming the transcription sector and healthcare as a whole. In addition to an emphasis on EHR adoption and the establishment of a nationwide health information exchange, a flurry of mergers and acquisitions has consolidated the number of medical transcription service organizations (MTSOs). This contraction, combined with new and more stringent regulations governing how protected health information (PHI) is handled, has made it more difficult to fly under the radar with questionable business practices.

“In the last five to seven years, everyone has been pretty tame,” says Dara Tribelhorn, CEO of Celerity Solutions Group, a full-service MTSO, and an active member of the Association for Healthcare Documentation Integrity (AHDI). “The focus is on the quality of the documentation and patient care. That’s it. No cutting corners or manipulating data. Organizations have put in standards, which has helped bring everyone together to say, ‘This is what the majority agrees upon.’ After the influx of the reduced rates that came with offshoring, everyone circled the wagons.”

Survival Strategy
The transcription industry first began paying serious attention to unethical business practices in the mid-2000s, when offshoring emerged as a popular business model to reduce costs, meet demands for faster turnaround times, and counter the continued shortage of qualified transcriptionists in the United States. As offshoring grew—by some estimates as much as 30% annually—so did concerns that there were not enough safeguards in place to prevent PHI from being breached or exploited by foreign transcriptionists. It was a fear that was realized in 2003 when a transcriptionist in Pakistan threatened to post patient reports from the University of California, San Francisco Medical Center if she did not receive back pay for her services.

These growing concerns eventually led AHIMA to publish a list of questions healthcare organizations should ask MTSOs to ensure their data would be kept secure even when they were sent overseas. It also caused MTSOs to accelerate the adoption of technology platforms that enabled remote transcription to be undertaken without ever being downloaded by offshore or home-based transcriptionists.

Going hand in hand with the offshoring of a larger volume of transcription was the rapid consolidation of the sector. What was once primarily a cottage industry is now dominated by large companies that have a different set of criteria to which they are accountable.

That’s according to Peter Preziosi, PhD, healthcare innovation strategist for Verizon Connected Healthcare Solutions and former CEO of AHDI and the Clinical Documentation Industry Association (CDIA), who notes that larger corporations have to operate more transparently than their smaller counterparts and are more apt to be the focus of regulatory scrutiny.

“If you are a very small operation that started by just putting out a shingle, you can stay under the radar. Now with consolidation and contraction, you’re seeing fewer of those companies, which enables regulators to go after business associates in a more meaningful way,” he says. “That’s been one of the challenges when it came to enforcement of HIPAA, false claims, and other regulatory concerns. It’s very difficult to evaluate and go after those [small] companies.”

In fact, it was the 2009 expansion of HIPAA, along with passage of ARRA, that spurred the transcription sector to step up its pursuit of ethical guidelines.

ARRA funded the push for the nationwide adoption of EHRs and other clinical information systems, while HIPAA put in place stringent technical safeguards that impact how MTSOs handle PHI. In the case of the latter, business associates with access to electronic PHI were required to have in place specific safeguards such as audit control and user identification. In addition, it was mandatory to retain PHI in a secure data center and establish technical controls over how home-based transcriptionists are able to access data.

“As many consumer advocates became more concerned about the handling and exchange of PHI … we continued to be concerned about just how well we in the medical transcription industry were handling PHI from an ethical and transparency standpoint,” says Preziosi. “Then, as we began to look at healthcare systems adopting EHRs and the way those EHRs document the encounter in template format, which at times does not capture the rich clinical information that a narrative captures within the dictation and transcription process, we became more concerned with the ethics around how care was documented and exchanged among providers in the healthcare system for fear there would be challenges around patient safety.”

Additional incentives to eradicate unethical business practices came in the form of the False Claims Act and the Anti-Kickback Statute, both of which carry heavy penalties, including jail time for violators. The Anti-Kickback Statute comes into play if an MTSO offers some sort of incentive for business or referrals. For example, offering an HIM director or a hospital executive gifts in exchange for a transcription contract could violate the statute, as could paying a fee in exchange for referring business to the MTSO.

The False Claims Act, which prohibits the submission of a false or fraudulent claim to the government for payment, applies to both healthcare organizations and their subcontractors or business associates. Examples of violations would be an MTSO that intentionally submits a claim to a Medicare facility with falsely inflated line counts or bills for an expedited report when one was not requested.

“Healthcare executives are challenged with the multitude of regulatory changes coming down the pipeline, issues related to how to engage and get actionable information into the hands of consumers,” says Preziosi. “I would venture to guess that many aren’t thinking about these ethical business practices and transparency as top of mind. But when you do start to look is when you start to see major fines being slapped on institutions. We’re seeing that now. The federal government is putting more money into greater surveillance. We are also seeing growth in the number of compliance officers.”

The consequences of falling into this nefarious world are substantial. “There is a lot of money at stake. I think people who are conducting business unethically, well, I wouldn’t want to be playing that kind of Russian roulette,” Preziosi says.

Taking Action
With so much at stake, it was clear that aggressive and proactive steps were required to ensure that MTSOs and individual transcriptionists were conducting business in an ethical and transparent manner. Thus, when the AHDI received more than $1 million as part of the settlement of a class action suit filed against MedQuist to fund programs for the general benefit of transcriptionists and the industry, one of its first actions was to develop the Manual of Ethical Best Practices for the Healthcare Documentation Sector.

Released in 2010, the manual was designed to assist documentation and medical transcription businesses and professionals adopt policies and procedures for complying with HIPAA privacy and security laws and operate in a manner consistent with best ethical practices related to transcription billing, compensation, and outsourcing. It includes the AHDI and the CDIA code of ethics and best practices for operations, billing, compensation, and marketing/solicitation. It also includes employee vs. independent contractor as well as exempt vs. nonexempt guidelines.

The manual features a section on the ethics of accurate time/date stamping on all transcribed reports and the appropriate use of e-signature inclusions and/or dictated but not read inclusions. It provides guidance on when it is acceptable to access, copy, and paste information from one patient report to another. It also includes guidelines and instructions for how a transcriptionist should handle requests that are unethical or represent a violation of policy or compliance. Finally, it spotlights multiple HIPAA-related sample policies and procedures and a sample business associate agreement.

The manual is one reason an ethics “manifesto isn’t necessary at this point,” says Tribelhorn. “AHDI and CDIA jointly put out best practices for MTSOs and anyone else in the industry … that shows compliance is in place.”

Another reason is that MTSOs themselves are taking greater steps to ensure they operate ethically and transparently. For example, Celerity’s baseline policies are that it will operate in full compliance with HIPAA at all times, and that the appropriate agreements are on file at the customer, employer, and employee levels.

These are “adhered to 100% of the time. Technology also, just by the nature of the beast, is 100% in compliance,” says Tribelhorn.

Celerity also focuses on maintaining a working environment that mitigates the risk that employees may be tempted to conduct themselves unprofessionally or unethically. The MTSO does not require noncompetes and ensures pay, benefits, and opportunities are fair.

That clarity and fairness also applies to how Celerity works with its customers and prospects, which is critical given that the majority of its business comes from word-of-mouth referrals.

“It’s all about honesty and integrity,” says Tribelhorn. “Get a list of references and call them. … Look at that list as a way to verify the [MTSO’s] honesty and integrity. Make sure they are fair, clear, and up front with contract negotiations and pricing, and that it’s not a muddled, 22-page agreement. Not every provider has a huge legal team behind them to review those documents before they sign off, so it’s smart for MTSOs to be clear and concise.”

Domination of the transcription industry by large corporations has also helped spur technical advances that are helping to eradicate unethical practices. Preziosi notes that surveillance technologies that provide audit tracking, the development of standard transaction specification, and more secure data exchange technologies all help prevent data manipulation and other fraudulent activities.

“The evolution of technology allows you to do greater surveillance but also tracking so you know who is touching a record,” he says. “When you get larger companies involved, it is a catalyst for change and it helps create outcomes that have greater accountability.”

— Elizabeth S. Roop is a Tampa, Florida-based freelance writer specializing in healthcare and HIT.