On Sept. 25, 2000, the Office of Inspector General (OIG) officially issued its “Compliance Program Guidance for Individual and Small Group Practices.” We first addressed the guidelines in the October 2000 issue; in November, we talked about how you can get started in developing a compliance program for your practice, if you choose to do so. This month, you’ll learn more of the details regarding implementation and enforcement.
Step 3: Designation of A Compliance Officer
Ideally one member of your practice will accept the responsibility of developing a corrective action plan, if necessary, and overseeing the practice’s adherence to that plan.
It is acceptable for a practice to designate more than one employee with compliance monitoring responsibility. You should describe in your standards and procedures the compliance functions for which designated employees (known as “compliance contacts”) would be responsible. For example, one employee could be responsible for preparing written standards and procedures, while another could be responsible for conducting or arranging for periodic audits and ensuring that billing questions are answered.
One individual could serve as compliance officer for more than one entity; or, the practice could outsource all or part of the functions of a compliance officer to a third party. If this role is outsourced, it is beneficial for the compliance officer to have sufficient interaction with the practice to be able to effectively understand the inner workings of the practice. Remember, you are ultimately responsible for any errors made by the consultant .
Designate someone to serve as a liaison with the outsourced compliance officer. This would help ensure a strong tie between the compliance officer and the practice’s daily operations.
If the practice decides to designate a particular person(s) to oversee all compliance activities, not just those in conjunction with the audit-related issue, the following is a list of suggested duties that the practice may want to assign to that person(s):
- overseeing and monitoring the implementation of the compliance program;
- establishing methods, such as periodic audits, to improve the practice’s efficiency and quality of services, and to reduce the practice’s vulnerability to fraud and abuse;
- periodically revising the compliance program in light of changes in the needs of the practice or changes in the law and in the standards and procedures of government and private payor health plans;
- developing, coordinating and participating in a training program that focuses on the components of the compliance program, and seeks to ensure that training materials are appropriate;
- ensuring that the Department of Health and Human Service’s (HHS)-OIG’s List of Excluded Individuals and Entities, and the General Services Administration’s List of Parties Debarred from Federal Programs have been checked with respect to all employees, medical staff and independent contractors;
- investigating any report or allegation concerning possible unethical or improper business practices, and monitoring subsequent corrective action and/or compliance.
You must assess your own practice situation and determine what best suits your practice in terms of compliance oversight.
Step 4: Appropriate Training, Education
Ideally, education programs will be tailored to the practice’s needs, specialty and size and will include both compliance and specific training.
There are three basic steps for setting up educational objectives:
- Determine who needs training (both in coding and billing and in compliance).
- Determine the type of training that best suits the practice’s needs (e.g., seminars, in-service training, self-study or other programs).
- Determine when and how often education is needed and how much each person should receive.
Training may be accomplished through a variety of means, including in-person training sessions (i.e., either on site or at outside seminars), distribution of newsletters, or even a readily accessible office bulletin board. Ensure that the necessary education is communicated effectively and that employees come away from the training with a better understanding of the issues covered.
Items to include in compliance training are:
- the operation and importance of the compliance program;
- the consequences of violating the standards and procedures set forth in the program;
- the role of each employee in the operation of the compliance program.
There are two goals a practice should strive for when conducting compliance training: all employees will receive training on how to perform their jobs in compliance with the standards of the practice and any applicable regulations; and each employee will understand that compliance is a condition of continued employment.
Compliance training focuses on explaining why the practice is developing and establishing a compliance program. The training should emphasize that following the standards and procedures will not get a practice employee in trouble, but violating the standards and procedures may subject the employee to disciplinary measures. It is advisable that new employees be trained on the compliance program as soon as possible after their start date and employees should receive refresher training on an annual basis, or as appropriate.
Coding and billing training on the federal health-care program requirements may be necessary for certain members of the staff, depending on their respective responsibilities. It is in the practice’s best interest to ensure that individuals who are directly involved with billing, coding or other aspects of the federal health-care programs receive extensive education specific to that individual’s responsibilities.
Examples of items that could be covered in coding and billing training include:
- coding requirements;
- claim development and submission processes;
- signing a form for a doctor without the doctor’s authorization;
- proper documentation of services rendered;
- proper billing standards and procedures and submission of accurate bills for services or items rendered to federal health-care program beneficiaries;
- the legal sanctions for submitting deliberately false or reckless billings.
Training may be conducted either in-house or by an outside source. Many community colleges offer certificate or associate degree programs in billing and coding, and professional associations provide various kinds of continuing education and certification programs. Many carriers also offer billing training.
In addition to the billing training, it is advisable for practices to maintain updated ICD-9, HCPCS and CPT manuals (in addition to the carrier bulletins construing those sources) and make them available to all employees involved in the billing process. Provide a source of continuous updates on current billing standards and procedures by making publications or government documents that describe current billing policies available to your employees.
There is no set formula for determining how often training sessions should occur. The OIG recommends that there be at least an annual training program and that new billing and coding employees be trained as soon as possible.
Step 5: Developing A CorrectiveAction Plan
If you detect a possible violation, you must develop a corrective action plan and determine how to respond to the problem. Violations of a practice’s compliance program, significant failures to comply with applicable federal or state law, and other types of misconduct threaten a practice’s status as a reliable, honest and trustworthy provider of healthcare.
Consequently, upon receipt of reports or reasonable indications of suspected noncompliance, it is important that the compliance contact or other practice employee look into the allegations to determine whether a significant violation of applicable law or the requirements of the compliance program has indeed occurred, and, if so, take decisive steps to correct the problem. As appropriate, such steps may involve a corrective action plan, the return of any overpayments, a report to the government, and/or a referral to law enforcement authorities.
Develop a set of monitors and warning indicators, which might include:
- significant changes in the number and/or types of claim rejections and/or reductions;
- correspondence from the carriers and insurers challenging the necessity or validity of claims;
- illogical patterns or unusual changes in the pattern of CPT-4, HCPCS or ICD-9 code utilization;
- high volumes of unusual charge or payment adjustment transactions.
If any of these warning indicators become apparent, it is recommended that the practice follow up on the issues. Later, as appropriate, the compliance procedures of the practice may need to be changed to prevent the problem from recurring.
For potential criminal violations, your practice’s compliance plan should include steps for prompt referral or disclosure to an appropriate government authority or law enforcement agency. In regard to overpayment issues, it is advised that the practice take appropriate corrective action, including prompt identification and repayment of any overpayment to the affected payor.
It is also recommended that the compliance program provide for a full internal assessment of all reports of detected violations. If the practice ignores reports of possible fraudulent activity, it is undermining the very purpose it hoped to achieve by implementing a compliance program, and any penalties imposed could be stiffer than if there had been no compliance program in place at all.
Include provisions in your compliance program to ensure that a violation is not compounded once discovered. In instances involving individual misconduct, the standards and procedures might also advise as to whether the individuals involved in the violation either be retrained, disciplined, or, if appropriate, terminated. Conduct a review of all confirmed violations, and, if appropriate, self-report the violations to the applicable authority.
If a violation occurred and was not detected, your compliance program may require modification. Periodically review and modify your compliance program.
Step 6: Developing Open Lines of Communication
In order to prevent problems from occurring, your practice needs to have open lines of communication. In the doctor practice setting, the communication element may be met by implementing a clear “open door” policy between the doctors and compliance personnel and practice employees. Post conspicuous notices in common areas and/or develop and place a compliance bulletin board where everyone in the practice can receive up-to-date compliance information.
A compliance program’s system for meaningful and open communication can include the following:
- the requirement that employees report conduct that a reasonable person would, in good faith, believe to be erroneous or fraudulent;
- the creation of a user-friendly process (such as an anonymous drop box for larger practices) for effectively reporting erroneous or fraudulent conduct;
- provisions in the standards and procedures that state that a failure to report erroneous or fraudulent conduct is a violation of the compliance program;
- the development of a simple and readily accessible procedure to process reports of erroneous or fraudulent conduct;
- if a billing company is used, communication to and from the billing company’s compliance officer/contact and other responsible staff to coordinate billing and compliance activities of the practice and the billing company (communication can include, as appropriate, lists of reported or identified concerns, initiation and the results of internal assessments, training needs, regulatory changes, and other operational and compliance matters);
- the utilization of a process that maintains the anonymity of the persons involved in the reported possible erroneous or fraudulent conduct and the person reporting the concern;
- provisions in the standards and procedures that there will be no retribution for reporting conduct that a reasonable person acting in good faith would have believed to be erroneous or fraudulent.
The OIG states that all practice employees, when seeking answers to questions or reporting potential instances of erroneous or fraudulent conduct, should know to whom to turn for assistance in these matters and should be able to do so without fear of retribution.
Step 7: Enforcing Disciplinary Standards
Incorporate measures into your practice to ensure that employees understand the consequences if they behave in a non-compliant manner. An effective compliance program includes procedures for enforcing and disciplining individuals who violate the practice’s compliance or other practice standards.
The OIG recommends that a practice’s enforcement and disciplinary mechanisms ensure that violations of the practice’s compliance policies will result in consistent and appropriate sanctions, including the possibility of termination, against the offending individual.
It is advisable, however, that the practice’s enforcement and disciplinary procedures be flexible enough to account for mitigating or aggravating circumstances. The procedures might also stipulate that individuals who fail to detect or report violations of the compliance program may also be subject to discipline. Disciplinary actions could include: warnings (oral); reprimands (written); probation; demotion; temporary suspension; termination; restitution of damages; and referral for criminal prosecution. Inclusion of disciplinary guidelines in in-house training and procedure manuals is sufficient to meet the “well-publicized” requirement of this element.
It is suggested that any communication resulting in the finding of non-compliant conduct be documented in the compliance files by including the date of incident, name of the reporting party, name of the person responsible for taking action, and the follow-up action taken. Another suggestion is for practices to conduct checks to make sure all current and potential practice employees are not listed on the OIG or GSA lists of individuals excluded from participation in federal healthcare or government procurement programs.
Developing Internal Controls:
Because You Want To You may view the implementation of a voluntary compliance program as comparable to a form of preventive medicine for the practice. This voluntary compliance program guidance is intended to assist practices in developing and implementing internal controls and procedures that promote adherence to federal health-care program requirements.
Ms. Green has been a practicing attorney since 1977. She is admitted to the practice of law in New York and Florida. She has formed numerous integrated practices throughout the country and acts as counsel to a number of multi-discipline practice consulting firms. If you have questions regarding compliance or any other legal health-care issues, please fax your questions to 914-666-9266; Law Office of Deborah A. Green, 16 Caren Court, Mt. Kisco, NY 10549; phone: 914-666-9264; firstname.lastname@example.org. Questions that are of interest to the broadest audience will be answered.
Because this article is being presented to you by an attorney, it would not be complete without a legal disclaimer. This article is provided subject to and governed expressly by the terms of this disclaimer. This article is provided for educational purposes only. The accuracy or timeliness of the information presented herein is not warranted. The information presented herein is not intended to be advice as to a specific fact pattern with which you may be presented. Accordingly, please note that the information contained herein is not being presented as legal advice with respect to any matter and that no attorney-client relationship is hereby established.