Why Your Medical Group Needs A Compliance Plan

HOUSTON, TX, February 27, 2014 (Press-News.org) Most physicians and others with small health care practices know that they should implement a compliance program to prevent billing issues, fraud and abuse, STARK violations and other potential problems, but they may simply not have had time. Soon, however, compliance plans will be more than a recommendation -- they will be required by law.

A Requirement Of The Affordable Care Act

Under the Patient Protection and Affordable Care Act of 2010, all areas of the health care industry will be required to have compliance programs, including individual physicians and small practice groups. Previously, health care providers who entered into corporate integrity agreements with the Office of Inspector General (OIG) were typically the only health care entities required to create compliance agreements. The Centers for Medicare & Medicaid Services (CMS) recommended voluntary compliance programs in other cases to help avoid erroneous claims and fraud, but did not require them.

The OIG has not yet published a deadline for implementing a compliance program, but it may be advisable to establish one now to avoid scrambling to create a program later. A compliance plan can minimize billing mistakes and reduce the likelihood of an audit by the OIG to search for abuse and fraud, violations of the anti-kickback statute and other health care laws. The OIG compares compliance plans to "practicing preventative medicine" for a medical practice.

Elements Of A Compliance Plan

CMS has issued guidelines for voluntary compliance plans over the years. These guidelines offer advice specifically for small group and individual practices. It generally recommends that a compliance program have seven components:

1. Conduct internal monitoring and auditing. Self-audits can determine whether bills are accurately coded, documentation is correct, services are reasonable and whether there are incentives for unnecessary services. Ongoing monitoring can address whether billing practices are acceptable and whether the compliance program is actually being followed.

2. Implement compliance and practice standards. A central part of a compliance program is the creation of written standards to reduce the risks found in an internal audit. Having a written policy can help identify risk areas, create tighter internal controls and reduce the risk of erroneous claims.

3. Identify a compliance officer or a compliance team. A compliance officer or team should be able to oversee the program and should have proper training.

4. Conduct appropriate training: Training should be tailored to your organization's needs and may be necessary for to understand compliance with the compliance program itself as well as issues such as proper coding.

5. Respond appropriately to reported violations: A compliance officer or team must promptly investigate allegations of violations of either the compliance policies or the law and take appropriate action.

6. Develop open lines of communication with employees: Larger medical practices may use processes such as hotlines that are too costly for smaller practices to adopt, but smaller organizations should have options for employees to freely report potential compliance issues.

7. Create disciplinary standards. A compliance plan should have disciplinary standards for violations, and these standards should be well-publicized.

Small group practices may not have the same needs or resources for compliance plans that large, complex health care organizations do, but compliance plans are beneficial as well as a legal requirement.

Kerr, Hendershot & Cannon is a Houston law firm with experience in health care compliance. We can establish an effective compliance plan that is tailored to your health care organization and can advise you on ongoing compliance issues. Call the Kerr, Hendershot & Cannon office today at 713-893-1668.