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Implement a Compliance Plan Before It's Too Late!

By Barry B. Cepelewicz
August 01, 2003

In this era of heightened scrutiny of health care practices, every provider of health care services or products (ie, medical practices, clinical laboratories, billing companies, durable medical equipment suppliers, etc.) must implement compliance plans to educate their employees to avoid questionable billing practices before they become the subject of government criminal or civil investigations or lawsuits. A voluntary and comprehensive compliance plan that addresses issues such as medical record documentation, billing, privacy and confidentiality, and fraud and abuse – which is implemented and complied with – may reduce the chances of an audit and minimize the criminal or civil liability of the practice or its principals in the event a problem arises. Under the sentencing guidelines issued by the U.S. Sentencing Commission, the sanctions that may be imposed for violations of the law may be reduced if the organization had an effective and meaningful compliance program in place before the bad conduct occurred. Therefore, even if the program failed to prevent and detect the illegal conduct, if the organization had in good faith taken reasonable steps to prevent such conduct from occurring, the criminal fines or other sanctions may be minimized.

In order to assist health care providers to develop and carry out effective and meaningful compliance plans, the Office of Inspector General of the United States Department of Health and Human Services (OIG) issued a series of compliance program guidelines, which include certain basic elements: 1) Creating and implementing written policies, procedures and standards of conduct; 2) Designating a compliance officer and/or committee, depending on the size of the organization; 3) Training and educating staff and employees; 4) Creating effective lines of communication between staff and the compliance officials; 5) Enforcing standards through well-publicized disciplinary guidelines; 6) Taking part in internal monitoring and auditing; and 7) Making prompt responses to detected offenses and implementing meaningful corrective action. The OIG recognizes that physician practices face financial and staffing constraints and not all elements of the model program can be implemented.

Any effort to create an effective compliance plan will involve identifying the areas of risk. This often requires focusing on areas that have been problematic in the past, such as coding and billing. Reviewing the claims denial history or claims that have resulted in repeated overpayment would be a logical place to begin. Such an exercise not only helps the practice identify significant risk areas, but will also improve cash flow by increasing the number of claims that are paid the first time they are submitted.

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