Medical Practice Compliance and Programs
[Accountability, Processes and Implementation]
By Patricia A. Trites
An increasingly common term in healthcare is “compliance program.” With Medicare and insurance carriers on the watch for fraud and abuse, and the increasing threats of Recovery Audit Contractors [RACs], a potential solution is an office system to help identify issues and correct them before government agencies get involved. These programs do not have to be complex, just functional. So, let’s start with the basics: What is a compliance program?
A medical compliance program, whether formal or informal, is a process or system to ensure that all regulatory requirements are being followed. In business, the annual financial audits are a customary part of an ongoing compliance program. Medical practices certainly have annual financial audits, but their compliance programs also expand into many additional arenas:
- proper Medicare coding and billing practices;
- compliance with various laws and regulations, notably the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Clinical Laboratory Improvement Act (CLIA), and Limited English Proficiency (LEP) programs;
- requirements imposed by the Environmental Protection Agency (EPA), Department of Transportation (DOT), and Occupational Safety and Health Administration (OSHA); and
- safety guidelines, patient privacy laws, accreditation and contracting of managed care services.
Healthcare compliance programs have been in existence for quite some time. Typically, they are the result of a governmental agency requirement in response to civil or criminal actions. In the event of some fiscal irresponsibility or irregularity, the federal government can impose a Corporate Integrity Agreement (CIA) that subjects the provider and/or organization to outside review. The entity that performs this review/audit has to report its findings to the governmental agency in order for the provider to continue doing business with the federal healthcare programs. These requirements are placed on large corporations and small solo-practice providers alike.
From a medical practice standpoint, the need for a compliance program can be made more relevant by evaluating the Medicare and Medicaid activities over the past couple of years. The Department of Health and Human Services (DHHS) Office of Inspector General (OIG) clearly states that there will be increased scrutiny in billing practices and compliance with billing procedures in physicians’ offices during the coming years. This is partially in response to the Balanced Budget Act [BBA] as well as the current healthcare reform political imbroglio.
Moreover, there are laws and regulations to follow, some are mandatory and others are just “strong suggestions”. But, as long as a provider is not under a government mandated corporate integrity agreement, most physician practices are not “required” to have a corporate compliance program. One exception is when a medical practice (healthcare organization) receives more than $5 million in Medicaid reimbursement annually. The Deficit Reduction Act [DRA] of 2005 requires medical organizations that meet this criterion to have policies and procedures in place to detect fraud and abuse and to train their employees on the fraud and abuse laws.
In fact, the OIG’s introduction to “Providers Self-Disclosure Protocol” states:
“The OIG believes that, as participants in the Federal health care programs, health care providers have an ethical and legal duty to ensure the integrity of their dealings with these programs. This duty includes an obligation to take measures, such as instituting a compliance program, to detect and prevent fraudulent, abusive and wasteful activities. It also encompasses the need to implement specific procedures and mechanisms to examine and resolve instances of noncompliance with program requirements.”
Nevertheless, on October 1, 2009, the Office of the Inspector General (OIG) released its work plan for the 2010 fiscal year. The 2010 plan includes reviews of and proposed changes to Medicare (Parts A, B, C, and D), Medicaid, and an additional section on the programs and efforts related to American Recovery and Reinvestment Act [ARRA]. This certification also contemplates “prospective” compliance, covering the period January 1, 2010 through December 31, 2010.
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