The compliance guidelines at a glance

Here are the basics of what has to be done

Following are the basics of the Office of the Inspector General’s (OIG) proposed guidelines defining what constitutes an acceptable physician compliance program. (For more information, see Physician’s Payment Update, July 2000.)

o Written policies and codes of conduct. It’s not a compliance program if your policies and procedures are not written down. Specific areas for which the OIG wants written policies and protocols are coding and billing; reasonable and necessary services; documentation; kickbacks, financial inducements, and self-referrals; and record retention.

o Compliance officer. Practices must designate one person from the staff to be responsible for overseeing the compliance program. More than one staffer or physician can be appointed to do compliance monitoring. You also can outsource part of all of the compliance officer’s responsibilities to a third party, such as a consultant, physician practice management company, management services organization, independent practice association, billing company, or professional association. Finally, you can place your practice under the compliance program of another institution, such as a hospital.

o Training and education. All employees must at least be familiar with the key risk areas identified in this guidance and the annual OIG Work Plan, which highlights the agency’s enforcement priorities for the coming year. The OIG wants to see new hires in compliance training within 60 days of coming aboard. It also wants practices to perform annual training that emphasizes that compliance is a condition of continued employment.

o Communication. There needs to be evidence of a clear open-door policy when it comes to registering concerns. That includes emphasizing employees can report any concerns without fear of retribution.

o Internal audits and monitoring. The OIG will be looking for regular self-audits of claims based on the practice’s top 10 denials — or top 10 services provided.

o Disciplinary actions. The program needs to have consistent and appropriate sanctions ranging from oral warnings to termination for anyone violating compliance rules.

o Responsiveness. Practices must quickly investigate and correct any possible compliance questions and take decisive steps to correct the problems. That includes returning any overpayments you uncover. Providers have a 90-day grace period from day of discovery to report possible problems to appropriate officials before the feds start wondering why you have not been more forthcoming.