Good compliance plan can save inquiries, headaches

Follow these OIG tips for an effective plan

Beefed up federal investigations into alleged fraud and abuse by health care providers mean physician practices that do not already have a formal plan for ensuring compliance with Medicare and Medicaid billing regulations should create one.

The Department of Health and Human Services’ Office of the Inspector General (OIG) has developed a set of guidelines that providers can use as a model compliance plan — or a checklist against which they can compare their existing plan.

A compliance plan is simply a set of rules and procedures designed to help guarantee your practice correctly complies with billing and documentation regulations required by the federal government and other relevant payers.

Just having a plan on file is not enough, however. If you are investigated, federal auditors will interview your employees to determine if your practice has been encouraging them to comply with your compliance plan.

According an OIG spokesperson, key elements of a properly designed compliance plan include:

1. Written standards. Develop a set of written standards that clearly outline office policies for preventing and dealing with potential fraud and abuse relating to billing and payment of federally funded health care programs. Copies of these written policies — and how they will be implemented — should be distributed to all office employees, plus any relevant outside reimbursement consultants.

2. Chief compliance officer. A specific individual or a committee of workers should be charged with developing a compliance program for the practice, plus supervising its implementation and ongoing operation.

To ensure success, the senior medical officers in the practice, plus the office manager, must reinforce the fact that it is official practice policy to stay in strict compliance with all regulatory and billing requirements. As such, compliance officers should have unrestricted access to senior practice executives.

3. Confidentiality. The program must ensure complete anonymity, confidentiality, and job security for anyone reporting questionable actions or behavior to the compliance officer.

4. Code of conduct. Have a written policy detailing what actions will be taken against those workers who fail to follow the compliance plan. This code of conduct should outline and explain what action to take when a potential problem or irregularity is discovered, along with how it will be investigated and corrected.

5. Records policy. Fundamental to a sound compliance program is a clear set of policies relating to records creation and retention.

6. Coding. All relevant employees must be continuously trained and updated in the proper assignment of ICD-9-CM and HCPCS codes, and related billing policies. As such, HHS recommends medical offices create and maintain an internal policy manual and guidebook that includes the latest policies and illustrated procedures for such things as superbills, obtaining needed insurance information, and processing payments.

7. Training program. Develop a compliance training program for any employees involved in the coding and billing process. The OIG recommends this training take place at least annually and be designed so all employees understand the potential legal and practical consequences of not abiding by the compliance plan and related federal regulations.

OIG also recommends that practices make complete compliance with appropriate reimbursement and billing rules a clearly stated condition of employment.

8. Self-audit. Office managers should regularly audit, monitor, and evaluate how well employees are complying with the plan to determine if plan modifications or additional training are needed.

9. Hiring. OIG says it should be compliance plan policy not to hire people who have either been convicted of a health care-related criminal offense or debarred, excluded, or ruled ineligible to participate in federally funded health care programs.

10. Performance evaluation. OIG recommends making adherence to the compliance plan part of the office manager’s and/or billing supervisor’s performance and salary review. Also recommended are punitive penalties for managers who fail to properly instruct or train subordinates in billing procedures or detect noncompliance problems.