July 8, 2022 | By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM
According to the U.S. Department of Health and Human Services (HHS) and the Office of Inspector General website, things have changed in regard to the controversial question of mandatory compliance plans.
The Federal Register / Vol. 65, No. 194 / Thursday, October 5, 2000, stated that:
“This Federal Register notice sets forth the recently issued Compliance Program Guidance for Individual and Small Group Physician Practices developed by the Office of Inspector General (OIG). The OIG has previously developed and published voluntary compliance program guidance focused on several other areas and aspects of the health care industry. We believe that the development and issuance of this voluntary compliance program guidance for individual and small group physician practices will serve as a positive step towards assisting providers in preventing the submission of erroneous claims or engaging in unlawful conduct involving the Federal health care programs.”
However, with the passage of the Patient Protection and Affordable Care Act of 2010 (ACA), physicians who treat Medicare and Medicaid beneficiaries will be required to establish a compliance program.
The need for an effective compliance program for healthcare organizations transitioned from voluntary to mandatory with the requirement in the Patient Protection and Affordable Care Act (PPACA) that healthcare providers applying to enroll as Medicare providers have a compliance program in place. So in effect, any healthcare provider that enrolled in the Medicare and/or Medicaid programs since 2010, agreed to develop and execute a Compliance Program into their practice as part of their enrollment agreement.
This guidance is for Individual and Small Group Physician Practices.
Per the OIG, establishing and following a compliance program will help physicians avoid fraudulent activities and ensure that they are submitting true and accurate claims. The following components provide a solid basis upon which a physician practice can create an impactful and needed compliance program:
- Conduct internal and external monitoring and auditing
- Many providers feel the need to code to the treatment and not to the documentation. If the procedure/treatment is fully documented, then the coding will be fully compliant
- Circling a code on a “superbill” or “chargemaster” is coding. Who is updating and monitoring these tools?
- Implement compliance and practice standards
- Designate a compliance officer or contact
- Conduct appropriate training and education
- Respond appropriately to detected offenses and develop corrective action
- Develop open lines of communication with employees
- Enforce disciplinary standards through well-publicized guidelines
What is a Compliance Plan?
A system to respond to allegations of improper conduct and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations or Federal health care program requirements.
Too many times we see practices that have developed a Compliance Plan but do nothing to enforce it and then when things go wrong, there is no trail of appropriate consequences for the conduct. You must enforce it. It would be like threatening a child with discipline for not following basic rules, and then not following through. You end up with repeated behavior.
What is the most important element in a compliance plan?
Operating in accordance with applicable laws and regulations. Creating a culture of honesty and integrity. Meeting high ethical and professional standards. Preventing fraud and abuse and other compliance issues should be the goal of every Compliance Plan.
What is the First or Core Element of an Effective Compliance Plan/Program?
The first core element of an effective compliance program is having written policies, procedures, and standards of conduct. Establishing written policies and procedures is necessary to promote consistency and uniformity in your office or practice.
Written policies and procedures should be written clearly and describe expectations of compliance in detail. These written policies, procedures and standards should be composed with guidance from the Compliance Officer (CO) and Compliance Committee. These guidelines also need to be made readily available for all of your employees. You and your compliance committee need to determine how these guidelines will be distributed, whether by hard copy, electronically, or on the Internet. All employees should be required to certify that they have read, understand and agree to comply with the standards.
One size does NOT fit all
It is important to note that compliance plans are not one size fits all. You will need to establish a plan that works for you and is specifically designed to meet your individual needs. So, while compliance plans should designate a compliance professional, what that will look like will vary depending on the size and structure of your practice/organization.
Medical Practices should budget for compliance, your livelihood may depend on it.