Use OIG guidances to form your own model plan’
Although the Department of Health and Human Services Office of Inspector General (OIG) hasn’t issued a model compliance guidance specifically for physician practices, common elements in other guidances have emerged that can help physicians develop effective compliance plans of their own.
The best place to start, experts say, is with the most consistently repeated section in each of the guidances issued so far: the OIG’s now famous seven compliance program elements.
"When it comes to the basics, we feel those seven elements are the fundamental components we’ll be looking for in any good-faith compliance program," says Lewis Morris, assistant inspector general for legal affairs at HHS.
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.
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.
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.