Risk Manager
Put Your Claims on Solid Footing
Here are the elements of an effective compliance program, which can protect your practice from costly penalties.
By Jeffrey D. Weinstock, ESQ.

In today's strict regulatory climate, physicians live with the knowledge that they may face a government inquiry on suspicion of submitting erroneous or fraudulent Medicare claims. Penalties can range from $5,000 to $10,000 for each claim under the False Claims Act, to substantial civil monetary penalties under other federal laws.

There's no way to be absolutely sure that your claims are 100% accurate, but implementing and adhering to a physician compliance program for all of your claims can alleviate most of your concerns. In addition, having a compliance plan can help to mitigate penalties in the event that your office is judged to have submitted an improper claim.

A PLAN PROTECTS YOUR PRACTICE

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services has issued Draft Compliance Program Guidance for Individual and Small Group Physician Practices (oig.hhs.gov/modcomp/cpgphysiciandraft.htm). Though not finalized, it offers guidelines for developing an effective compliance plan.

The OIG document also identifies the greatest areas of risk for false or erroneous claims, including errors in coding and billing, inadequate services documentation, improper inducements, kickbacks and self-referrals.

The sooner you implement a compliance plan, the sooner you can benefit from the protection it provides.

The plan will help your practice to:

• develop internal procedures that ensure compliance with regulations
• improve your system for medical records documentation
• educate staff members about the importance of compliance issues
• reduce the number of denied claims
• lessen exposure to penalties and liability arising from noncompliance.

FOLLOW THE GUIDELINES

According to the OIG's guidelines, a compliance program should contain the following elements:

• written policies and standards of proper conduct
• a compliance officer or contact (a responsible staff member who sees to it that the regulations are followed)
• relevant staff training and educational programs
• timely communications that keep staff members updated about compliance activities
• regular internal audits to monitor and ensure compliance
• enforcement of standards through clearly stated disciplinary directives
• a mechanism for prompt corrective action if an improper claim is submitted.

PUTTING YOUR PLAN IN ACTION

A good compliance program will not only prevent you from submitting fraudulent or erroneous claims, it will also show the OIG that your office is making a serious effort to comply with the law.

Having effective compliance policies can help mitigate any legal sanctions -- if the plan was in place at the time the offense was committed.

Keep in mind that your program won't be considered effective if it isn't being followed. It's not enough to simply pay an attorney to draft a compliance program that gathers dust on the your office administrator's bookshelf. The burden is on the practice to demonstrate that it places a priority on compliance.

Every practice is different, and the needs of each practice will determine the type of compliance program that's required. It's a good idea to first review the general guidelines set forth by the OIG. You should also contact your practice's attorney for advice on how to implement a program that's best suited for your practice.

Jeffrey D. Weinstock, Esq., is an attorney with Sachs, Sax and Klein, P.A., in Boca Raton, Fla. He practices healthcare and corporate law. Risk Manager provides a general summary of legal issues and should not be construed as personal legal advice. Application of these principals varies according to individual situations.