OIG hospital compliance plan: No immunity
OIG hospital compliance plan: No immunity
Should become `fabric of routine' for hospitals
Stressing that the plan is voluntary, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services, has issued its long-awaited model hospital compliance plan, outlining the key elements that should be contained in a compliance plan and the overall importance to a hospital's "fabric of routine" of a compliance officer and committee.
The plan, titled The Office of Inspector General's Compliance Program Guidance for Hospitals, emphasizes the importance of establishing a "culture within a hospital that promotes prevention, detection, and resolution of instances of conduct that do not conform to federal and state law, and federal, state, and private payer health care program requirements, as well as the hospital's ethical and business policies."
In its introduction, the OIG points out that having a compliance plan is not a sure fire insurance policy against civil damages and penalties or criminal sanctions if health care fraud is found out; nor is voluntarily disclosing a violation of health care law. The OIG states unequivocally that under the False Claims Act, "a person who has violated the Act but who voluntarily discloses the violation to the Government, in certain circumstances will be subject to not less than double, as opposed to treble, damages."
If the compliance officer has reason to believe that a violation of criminal, civil, or administrative law has occurred, then the hospital "promptly should report the existence of misconduct to the [OIG or the Department of Justice] within a reasonable period but not more than 60 days after determining that there is credible evidence of a violation."
In fact, some violations may be so serious that they warrant immediate notification to governmental authorities prior to or simultaneously with starting an internal investigation, the OIG states.
To qualify for the "not less than double damages," a report of a False Claims Act violation must be provided to the government within 30 days after the date the hospital confirms that a violation has occurred.
Chicago-based American Health Information Management Association is "pleased" with the plan, it said in a statement following the announcement. "The OIG has given health care providers an excellent resource for developing effective internal controls to ensure regulatory adherence," says Sue Prophet, RRA, CCS, director of classification and coding. "Now, it's up to the industry to take the ball and run with it."
AHIMA plans to publish its own model HIM compliance plan, Prophet says. It will be finished in late summer or early fall.
What about the expense of developing and implementing a compliance plan? "My feeling is that the long-run benefits far outweigh the costs," Prophet says. "You will end up with more efficient management and improved documentation, which could even rectify some malpractice suits because documentation all the way around will be better. Operations will be better; you could actually be saving money. This sort of forces you to document everything upfront so you don't have to run around after a claim is denied, after the fact and resolve it.
"It could improve productivity because now there'll be written policies, and staff will know where to find the bulletins because now they'll be forced to have all this information available and accessible - and spend more time doing their jobs," she says.
Heavy emphasis is placed on starting a compliance plan at the top with a commitment by top management. That, says Prophet, is a good idea. "They haven't really gone after the coders anyway. They've been looking at it more like the employees are following the corporate policies and procedures, and you at the higher level are responsible for the work of the employees."
Every effective compliance plan must include all of the following seven elements, the document states:
1. The development and distribution of written standards of conduct, as well as written policies and procedures that promote the hospital's commitment to compliance (e.g., by including adherence to compliance as an element in evaluating managers and employees) and that address specific areas of potential fraud, such as claims development and submission processes, code gaming, and financial relationships with physicians and other health care professionals.
2. The designation of a chief compliance officer and other appropriate bodies, e.g., a corporate compliance committee, charged with the responsibility of operating and monitoring the compliance program, and who report directly to the CEO and the governing body.
3. The development and implementation of regular, effective education and training programs for all affected employees.
4. The maintenance of a process, such as a hotline, to receive complaints and the adoption of procedures to protect the anonymity of complainants and to protect whistle-blowers from retaliation.
5. The development of a system to respond to allegations of improper/illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations, or federal health care program requirements.
6. The use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas.
7. The investigation and remediation of identified systemic problems and the development of policies to address the non-employment or retention of sanctioned individuals. Not surprisingly, claim development and submission policies get special attention in the OIG's model plan - a foundation of HIM responsibilities.
"The basics of HIM that have been there all along," Prophet says. "Documentation and coding that matches that documentation." Another keystone of the plan is the emphasis on educating not just coders but physicians and ancillary departments. "HIM professionals certainly have a role to play in that process," Prophet adds. n
You can access the Office of Inspector General's Compliance Plan Guidance for Hospitals on-line at American Health Consultants' Web site, http://www.ahcpub.com, under the heading Special Coverage. You'll need a PDF file reader to download the document.
For a paper copy, write to: DHHS, Office of Inspector General, 330 Independence Avenue, SW, Room 5541, Washington, DC 20201, Attention: Public Affairs. Or call: (202) 619-1142. Leave a message giving the name of the document, your name, address, and phone number, and it will be mailed to you.
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