Coding & Reimbursement

Getting compliance plans right

They will soon be mandatory, so prepare now.

By Suzanne L. Corcoran

Compliance plans are optional for the time being, but don’t get too comfortable — the Affordable Care Act (ACA) requires them. Here are some action items to think about before they become mandatory.

Q. What is the OIG’s compliance program for physician practices?

A. The Office of Inspector General (OIG) previously developed a voluntary compliance program focused on several areas and aspects of the health-care industry. The OIG believes that developing a compliance program for individual and small-group physician practices will help providers avoid erroneous claims and unlawful conduct involving federal health-care programs.

Although no deadline for mandatory implementation has been established, the Patient Protection and Affordable Care Act states, in Section 6401, that “...a provider of medical or other items or services … shall, as a condition of enrollment in the program under this Title ... establish a compliance program.” This means that physicians’ ability to enroll in federally funded programs, including Medicare and Medicaid, will hinge on whether the practice has established a formal compliance program.

Q. Who will establish the mandatory guidelines and set the implementation date?

A. The Secretary of Health and Human Services, with assistance from the OIG, will establish the core elements of a program and set the required implementation date. In a CMS webinar discussing compliance programs, listeners were encouraged to consider developing a program, even though no official deadline has been established.

Q. What is involved in developing a compliance program?

A. It is actually a two-step process, and there is no one-size-fits-all plan. So the first step is to develop a written plan. Plan templates to help you get started are available from a variety of sources; customize one to create a unique plan for your practice. Depending on the size and structure of the practice, legal counsel and/or outside consultants may be required to assist in analyzing contracts, performing a chart review and conducting necessary training.

The second step is putting the program in motion by converting the written document into multiple activities. The activities are not one-time occurrences; therefore, the practice needs to commit to the program for the long term.

Q. What guidelines exist to assist with developing a program?

A. In October 2000, the OIG published Compliance Program Guidance for Individual and Small Group Physician Practices. Many speculate that this guidance will be used when formulating the core elements as directed by the ACA. You can find this document at: http://oig.hhs.gov/authorities/docs/physician.pdf. The OIG’s seven core elements are:

1. Conducting internal monitoring and auditing

2. Implementing compliance and practice standards

3. Designating a compliance officer or contact

4. Conducting appropriate training and education

5. Responding appropriately to detected offenses and developing corrective action

6. Developing open lines of communication

7. Enforcing disciplinary standards through well-publicized guidelines.

In addition, practices should check the OIG’s list of excluded individuals. This is simple. You can find it at: http://oig.hhs.gov/. It is a large button on the OIG site that reads, “Exclusions Database.” You can search for a single name or a list of names. Failure to check the exclusions database is a common compliance error.

Q. What is the role and responsibility of a compliance officer?

A. The compliance officer should be someone of moderate authority because, while the role(s) and responsibilities may vary depending on the size of the practice, in general, they include:

• Overseeing the program

• Establishing methods to improve quality and efficiency

• Revising the plan as needed

• Developing, coordinating and participating in training programs

• Checking the OIG’s list of “Parties Debarred from Federal Programs”

• Investigating any allegations of unethical or improper conduct

• Monitoring corrective action programs.

Q. Are there any benefits to having a voluntary compliance program before it’s required?

A. Yes; developing a program will reveal a practice’s strengths and weaknesses. At the same time, you will develop benchmarks, goals and objectives for the practice. Having a compliance program also offers several benefits, as cited in the Federal Register (volume 65; number 194; Oct. 5, 2000). They include:

• Speeding and optimizing proper payment of claims

• Minimizing billing mistakes

• Reducing the chances that CMS or the OIG will conduct an audit

• Avoiding conflicts with the self-referral and anti-kickback statutes

• Demonstrating a good-faith effort to comply with laws and regulations

• Indicating that staff members have an affirmative, ethical duty to report billing errors or fraudulent conduct so it may be corrected. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.