Compliance Corner

Start the Year Right: Review Your Compliance Plan

Organizing a review committee and keeping staff informed help keep a practice out of hot water.

By Jolynn Cook, RN, COE, CASC

Developing and annually reviewing a compliance plan (CP) is no small task. The CP should be more than just a binder sitting on the shelf. This document should serve as a source of reference and guidance to practice managers. If the administrative team still needs to develop a CP, legal counsel is advised for guidance and review prior to implementation. Many great resources are available to assist ophthalmic practices with this endeavor.

Following the final approvals of counsel and physicians, management and employees must be educated in order to clearly understand the CP. In our practice, a copy of the CP is provided to each new employee by including it as an addendum in our employee information guide. In recent years, our hard-copy manuals have evolved into electronic shared documents and files. Updating our practice’s policies and various reference materials enable employees “read-only” access to this information 24/7 from any location that offers Internet access.

Appoint a Committee

The CP should include a written plan that is easily understood by all employees. Physicians and/or administrators should appoint the compliance committee from a pool of doctors, managers and employees who represent the various departments, such as clinical, optical, and front desk.The committee will be tasked with implementation of the plan followed by an annual review, along with investigating any alleged noncompliance.

In our practice, the committee meets annually to review the CP and make any needed updates. Should an issue arise between meetings, the members will be summoned to meet. Members are charged with providing an impartial review of the alleged violation. The committee is responsible for addressing any concerns or issues that may arise regarding practicewide compliance violations or to investigate reported risk of violation. A CP should include compliance with Federal and State regulations including:

■ OSHA

■ HIPAA Compliance

■ Compliance with CMS guidelines

■ Fair Labor Standards Act/Wage and Hour

■ EEOC

■ Stark Laws and compliance with contractual agreements with various payors.

Employee Obligations

We include compliance with our internal policies and procedures recognizing that there may be overlap between the abovementioned areas. The CP also details a “standards of conduct,” which includes the obligation to report any known or suspected violations or non-compliance with the laws and regulations listed above.

Our employees have a responsibility to report any concern regarding violation of any laws or regulations. We request all complaints and concerns are “filed” internally before seeking assistance from governmental agencies. Our compliance committee is dedicated to our mission of adhering to established guidelines, regulations and laws, to the best of our ability. Our policy clearly holds employees accountable should the employee become aware of any violation of any law, regulation or policy and neglect to report said violation.

Annual Training Day

Like many other practices, we hold an annual compliance-training day. We gather, usually on a Saturday, to provide education and training on OSHA, HIPAA, IT Security, EEOC laws. During the meeting, we review any compliance-related updates from the prior year. At the conclusion of the program, each employee is asked to sign off on a “compliance questionnaire” by selecting one of two choices:

    ___ I am not aware of any ethical or legal compliance issues under any kick-back statute; any self referral act; Medicare, Medicaid and others…

    ___ I am aware of the following ethical or compliance issues which I feel should be looked into (please list issues here):

This document is reviewed and signed annually and kept in the employee’s personnel file. It is also signed whenever an employee leaves the practice.

The practice has a toll free compliance hotline to provide our employees, contractors, patients and others with a means of informing the practice of any known or suspected violation of the standards of conduct, requirements by payors, or violation of any state or federal regulation. The hotline enables the caller to leave information anonymously.

Compliance is one of the most important responsibilities a practice administrator has. A well-designed CP, an involved compliance committee and a committed administrative team will mitigate risks facing — and provide an extra layer of protection for — your ophthalmic practice. OP

Ms. Cook is the Administrator of the Laurel Eye Clinic and the Laurel Laser & Surgery Centers. A Certified Ophthalmic Executive and a Certified Administrator Surgery Center (CASC.), Ms. Cook is a registered nurse and also has a degree in Health Care Administration.