Compliance

Review your practice’s program

An effective compliance program requires several key components.

BY C. JOLYNN COOK, RN

Physician practices are required to have compliance programs in place since the Department of Health and Human Resources, Office of the Inspector General (OIG) published this requirement in the Federal Register in 2000.

This initiative was put into place to ensure that health-care providers, including physician practices, submitted proper claims by minimizing billing mistakes and prevent fraudulent conduct by implementing internal controls and monitoring methods.

Even if you already have a compliance program, it may be helpful to update it. Review some of the key components identified by the OIG that need to be included in an effective program.

Internal monitoring and auditing

Our practice has a chart review committee comprised of our patient accounting department staff and technicians. At a monthly meeting, the committee usually selects one doctor and reviews multiple records for that particular physician. Then, they provide a report to the physician that summarizes their accuracy, proper coding, proper documentation, and completeness. They document the meeting results, and the patient accounts manager provides any necessary follow-up training or education. If concerns exist, management follows up or reviews additional records.

Practice standards and procedures

For many reasons, including compliance, your practice should establish written policies and procedures. More importantly, management should insist that everyone follows the policies and procedures. In particular, focus on mitigating risk and identifying areas that may be at risk. To make compliance successful, keep electronic health record templates updated to ensure that patient care is clearly and appropriately documented.

Someone in the practice, typically the manager or person responsible for billing, must stay informed and current on directives from the federal and state programs, such as Medicare information and other updates from the OIG or payors should standards and procedures need updates. The OIG identifies “risk areas” where special focus is required: coding and billing, reasonable and necessary services, documentation, and improper inducements.

Compliance officers

The OIG requires that practices have a designated compliance officer. The officer needs to be dependable and can complete compliance functions and follow through with attention to detail. Additionally, the compliance officer must have a good rapport with the physicians and employees to make changes when needed.

Appropriate training and education

Each physician and employees must understand that compliance with laws and regulations is not negotiable, so education is vital. You can educate staff in several ways, including person-to-person, webinars, in-service/group training and distance learning programs.

To ensure that participants learn from the training, distribute a quiz. Along with the quiz, keep any handout material or certificates to document the content and completion of the educational program.

Responses to potential and actual offenses

Parties must be held accountable for violations to any policy and procedure in place. Without accountability, policies and procedures are essentially meaningless. To make your program effective, develop corrective action plans. Internal assessments, such as careful investigation and audits, are a critical part of determining when policies are violated, ensuring compliance and making any necessary updates or changes to the plan.

Open lines of communication

This is essential to ensuring that everyone works together, that all parties understand the goals, and objectives and that all policies and procedures are clearly communicated. Employees must have confidence should they need to report erroneous or fraudulent conduct.

Although that person may ask to remain anonymous, always make it clear that there may be a point during the investigation of an incident where the individual’s identity may become known. For example, while auditing billing records, the name of the employee who reports the conduct would quickly become apparent if/when Medicare or law enforcement has to be notified. Avoid promise — leaders must be trustworthy and open.

Disciplinary standards

Every employee must understand the consequences if they choose to be non-compliant with the laws of the government (Medicare/Medicaid) and the policies of the practice. Non-compliance with laws or regulations set for by government programs likely will not and should not be tolerated by the practice, and disregard would result in termination of employment. Depending on the seriousness of the offense, it may result in criminal charges for the employee and/or the practice.

Conclusion

Just as the circumstances are different in every situation, so are the appropriate actions. Developing a compliance plan that is easily understood will help to support a healthy culture where disregard for regulatory compliance is not tolerated. OP

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