Written by: Joanne Byron, BS, LPN, CCA, CMDP, CHA, CIFHA, CHBS, CHCO, CHCM, OHCC, ICDCT-CM/PCS
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The information contained in this article is not provided as legal or consulting advice. Please retain legal, consulting, and accounting professionals prior to starting your business.
Personal Qualifications
Coders and health care compliance auditors must have the type of personality which promotes attention to detail. Coders can often be classified in the same personality category as IT “nerds,” but remember, starting your business means you must have the ability to connect with your clients!
Ask yourself if you enjoy initiating “small talk” to fill in awkward gaps in conversation during a client meeting. Let me give you an example. The client’s Practice Administrator wants to retain your services, but needs the lead provider’s approval. A lunch meeting appointment is made with you, the provider, and the Practice Administrator. Introductions are made, the provider’s cell phone rings, and s/he steps away to take the call. You already interviewed with the Practice Administrator – this is a perfect time to connect personally and create an actual relationship.
Expertise, honesty, and transparency is important. Never “oversell” yourself and take an engagement beyond your expertise. Know in advance your strengths and weaknesses and be willing to share that information with prospective clients.
Be up-front about your rates. Don’t surprise a client by invoicing more than what the client expected. Provide a reasonable quote and make sure the client agrees to provide the information needed for the engagement. It is best to have a simple Letter of Agreement with everything spelled out (see below about retaining professionals to help you get started).
Partnering with your clients helps the client feel you are not only engaged in the project but invested in the outcome. Consultants with this type of reputation are more likely to succeed.
Qualifications in the Area of Education & Experience
Are you qualified to be a consultant? Organizations retain consultants to obtain official consulting advice from an “expert.” Research the education and credentials of other consultants in your field to ensure your background, education, and credentials at least match or exceed that of your competition.
For instance, if you start a coding and auditing consulting business, determine your coding expertise strengths. This will set you apart from the typical coder with some consulting experience - ask yourself these types of questions:
- What type of coding and auditing are you qualified to do?
o Most organizations value coders with at least 5-10 years of experience in their specialty - Do you have experience working with providers under a probe or investigation?
o This would be experience dealing with government investigators on behalf of the provider to request additional time to produce records, request extensions, and prepare documentation in response to a Request for Information (RFI). - Do you have extensive experience appealing denied claims?
o If so, how many appeal levels?
o What is your success rate in getting a denial overturned?
o Do you have appeals experienced related to a CERT (comprehensive error rate testing) denial or CMS probe? - Do you have experience as an expert witness in fraud cases?
o Are you experienced in working under Attorney-Client privilege?
o Have you provided a provider’s legal counsel with coding and documentation advice related to a legal case? - What is your education? BS, BSN, LPN with college, MBA, RHIA, RHIT?
o Does your education provide you with the credibility needed to prove you can read and interpret clinical notes of the provider?
o What is the education of your competition? - Are you a certified coder?
o Certification in coding is the means to obtain the Error & Omissions (E&O) liability insurance you need to be a consultant.
o Do you have 5-10 years of experience coding? - Are you a certified auditor?
o Consultants often need more than experience in auditing charts. Overall compliance audit training is required to detect violations of the Anti-Kickback Statutes, Stark Law (physician self-referral law), and False Claims Act.
o Are you certified as a health care compliance auditor (i.e. CHA) or certified in conducting internal investigations?
o What type of auditing credentials do your competition have? Is it needed? - Do you have the extensive HIPAA training needed?
o You will become a Business Associate and be asked to sign Business Associate Agreements (BAA) by your clients. The Covered Entity is responsible for executing the BAA. Never sign a BAA that will restrict your ability to fulfill your engagement obligations with the client.
o Do you have extensive HIPAA privacy and security training? This can be an added advantage to provide additional confidence to potential clients that the Protected Health Information (PHI) they are entrusting to you and your business will be safe.
Retaining Legal & Accounting Advice
If you believe you have the personality to strive for success and the education, experience and credentials needed, the next step is to speak with an attorney and accountant to determine the type of corporation you need to establish to protect your personal assets and have the ability to file monthly or quarterly tax returns as a corporation.
Get advice from your attorney regarding the type of liability insurance you need. Contact your professional organization to see if they have partnered with an insurance company for discounted liability E&O policy rates.
Additional Credentials to Qualify as a Consultant
Please investigate all potential credentials available that will give you the advantage you need to succeed in your business and add value to your already extensive talent. Check out these training options, with the option to certify, that are perfect for consultants:
- Certified Healthcare Auditor (CHA) – auditing for compliance. Training to plan the audit, execute the audit, report your findings, and take corrective action.
- Certified Internal Forensic Healthcare Auditor (CIFHA) – understand how to gather information related to an internal investigation of potential fraud.
- Certified HIPAA Compliance Officer (CHCO) – learn Privacy & Security Rules, the role of a Business Associate and contents of a BAA, breach notification rules, and legal requirements of Business Associates according to HIPAA law.
- Are you a more 'visual' learner? Attend our professional Live Training Events!
American Institute of Healthcare Compliance, Inc. (AIHC)
A Non-Profit 501(c)(3) Organization
