Use these seven elements as model
New guidelines issued by the Department of Health and Human Services (HHS) to help hospitals design their anti-fraud and abuse compliance programs can also be used by physician practices as a broad blueprint for their own compliance programs, HHS officials told Physician's Payment Update.
"Naturally, when it comes to specifics there are some things we'd expect to see in a comprehensive hospital plan that wouldn't be part of a physician's practice compliance plan," says Lewis Morris, assistant inspector general for legal affairs at HHS. "But when it comes to the basics, we feel the seven elements referred to in the hospital guidance are the fundamental components we'll be looking for in any good-faith compliance program."
These seven key elements are:
1. Written policies and procedures promoting compliance and addressing specific areas of potential fraud. This may address areas such as claims development and submission processes, code gaming, and financial relationships with physicians and other health care professionals.
2. Designation of a chief compliance officer and "other appropriate bodies" who report directly to the CEO and governing body to promote and ensure compliance with federal reimbursement rules. (See related article on p. 68 for more on choosing a compliance officer.)
3. Regular, effective education and training in related reimbursement and billing regulations for all affected employees.
4. Mechanisms and processes such as a hot line for employees and/or patients to report possible problems to the internal compliance office along with procedures that "protect the anonymity of complainants and . . . whistleblowers from retaliation."
5. Systems "to respond to allegations of improper/illegal activities" and enforce appropriate disciplinary action against employees who violate internal compliance policies and other legal/regulatory requirements.
6. Regular audits or other evaluation techniques that monitor potential problems and ensure proper compliance procedures are being followed.
7. Prompt investigation and correction of systemic problems once they are identified, along with policies for disciplining and/or firing employees for improper compliance behavior.
Many practice administrators wonder exactly how long they have to report a suspected problem uncovered by their compliance program. According to HHS Inspector General June Gibbs Brown, "If a provider discovers credible evidence of misconduct from any source and, after reasonable inquiry, has reason to believe that the misconduct may violate the law, then the hospital should promptly report the existence of misconduct to the appropriate governmental authority within a reasonable period . . . not more than 60 days after determining that there is credible evidence of a violation." What this really means is that the 60-day clock does not start ticking after receiving a tip on the practice's telephone hotline, for example. But the clock does begin running immediately after the allegation is investigated internally and it's been determined that a possible problem exists.
As an incentive to report suspected problems, federal investigators "will consider the existence of an effective compliance plan that pre-dated any governmental investigation when addressing the appropriateness of administrative penalties," the guidance notes. Plus, voluntarily disclosing violations reduces possible damages to double - rather than triple - the money in question, under the False Claims Act, note OIG officials.
Meanwhile, providers "are on notice that if they are not in compliance with these guidelines, they are vulnerable to extreme penalties," Brown said. "We expect all providers to refund any overbillings they might discover that happened in the past. But, we are not looking to nail them for anything further, so they should not have any fears about stepping forward. In fact, it will go much better if they bring these things to our attention rather than us finding out on our own," advises an investigator in the OIG's office.
The OIG also recommends that providers avoid appointing their in-house counsel or outside lawyer, head billing manager, or chief financial officer as the senior compliance officer. This could result in a possible conflict of interest, in turn reducing the program's surface credibility with federal auditors.
Besides the hospital program, additional compliance guidelines for home health agencies, billing companies, HMOs, and durable medical equipment suppliers are expected to be released by HHS before the end of the year, according to Brown. "If a couple of errors by the same provi der come up on our screen, we generally assume these are just honest mistakes, ask for the money back, and forget about it," says Morris. "But if we find the same mistake being made over and over again, that raises a red flag."
According to the OIG's office, specific billing and claim "red flags" sure to grab a federal auditor's attention include indications of:
· bills for items or services not actually rendered;
· claims for seemingly unnecessary medical services;
· upcoding services provided to a higher-than-justified procedure;
· charging for improper outpatient services rendered in connection with inpatient stays;
· illegally billing for medical services of a teaching physician actually provided by a resident requirements at a teaching hospitals;
· filing duplicate billing and false cost reports;
· improperly unbundling services included in a specific code and individually rebilling them to increase the amount of a claim;
· inflating bills by inappropriately billing the transfer of a patient to another hospital or special care facility.
Also on the OIG's red flag list are: repeated failures to refund any credit balances due patients or the government; physician incentives that might violate the anti-kickback or self-referral statutes; seemingly overgenerous financial arrangements between hospitals and hospital-based physicians; and failure to provide covered services or necessary care to HMO members.