Planning Strategies
Compliance Efforts Falling Short
As the OIG list of sanctioned providers grows, are you sure you won't be next?
BY RICHARD E. GABLE, PH.D., M.B.A., CEO

Fraud and abuse regulations have had an increasing impact on the healthcare industry in recent years. A heightened enforcement commitment by governmental agencies -- accompanied by increases in these agencies' staffs -- has made the likelihood of investigations and subsequent sanctions greater. We're also seeing a trend toward stricter settlements in these cases.

This month, I'll discuss some of the newer issues surrounding compliance programs. In next month's column, I'll suggest ways to overcome the challenges of implementing an effective program.

Because health care is a fragmented and local industry, the Office of the Inspector General (OIG) enforces regulations in a way that makes providers responsible for reporting information honestly and with adequate documentation. The OIG's primary purpose is to ensure that providers play by the rules, a mission whose intent is to help the overall healthcare industry.

REGULATORS HAVE THE DATA

It's fairly easy for the regulators to identify noncompliant providers. The authorities have access to Medicare and Medicaid data, which comprises the majority of most providers' reimbursement. They're also able to screen data samples to identify areas of potential provider errors.

Many providers don't track their own billing data, which makes them even more vulnerable to regulatory sanctions. The OIG is now posting the names of sanctioned providers at www.hhs.gov/oig. Once on that Web site, you can click on "exclusions database" and download the list.

Despite the severe consequences of sanctions, some providers still haven't gotten the message. Their "compliance programs" sit on the shelves in administrative offices. Few have implemented changes, and fewer yet have tracked the response to the changes they've enacted. Not enough providers actively monitor their compliance programs to proactively avoid a sanction or investigation.

A GROWING CONCERN

The risk for noncompliance has now begun to involve top administrators in large group practices. Administrators are becoming aware of their exposure and are actively seeking assistance.

To obtain meaningful help, you must first know the level of risk. This is the problem for most practices. They don't know the extent of their exposure. Many practices will simply underbill, mistakenly thinking that the "feds" will leave them alone.

The maze of regulations facing medical practices today has reached a point where it requires expert analysis and interpretation. Now, regulations are often clarified through the courts, though the OIG does make a major effort to provide clear guidance on how to comply with the rules. (See www.oig.hhs.gov/cia/ciafaq1.htm.) If many in the healthcare industry keep skirting the issue of enacting strong compliance programs, a continued barrage of sanctions will be the result.

COMPLIANCE IS A SIGN OF QUALITY

Healthcare compliance programs are frequently compared to the quality management efforts that have been so popular in industry. And ample supporting data suggest that good compliance is good business.

Yet many providers don't monitor their compliance programs objectively and don't know the impact of their own compliance program on their business. Although it makes good business sense for each provider to strive for perfection, the OIG doesn't expect your compliance program to be perfect. You're allowed an occasional error.

Nevertheless, many practices will have to do much better in their compliance efforts -- and to improve they'll need help.

In next month's column, I'll discuss the current appalling lack of proven provider support tools (primarily software) for monitoring billing compliance. I'll also make some suggestions that will help you police your own practice. 

Dr. Gable is chief executive officer of Dynamic Health Connections, Inc., in Lake Forest, Calif., which provides specialized consulting expertise for subspecialty physician groups, managed care organizations and other medical organizations. You can reach him at dhc38@aol.com.