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Protect Your Practice With a Medicare and Medicaid Compliance Program

Protect Your Practice With a Medicare and Medicaid Compliance Program

Posted by-Lawerslog
Member Since-29 Dec 2015

What is a compliance programme?

You should implement a health care compliance plan to protect your federally-funded health care programs. This program will include a variety of internal controls and measures. These components may be included in a compliance program:

Contract and operating procedure legal reviews

Training and directives for employees

Mechanisms for monitoring and auditing

Reporting violations of your plan and government regulations.

A compliance program can be used to prevent misconduct in a workplace. It can also help identify and stop misconduct before it escalates into a larger problem, such as an OIG investigation. A compliance program can help reduce the chance that an employee who is unhappy will file a whistleblower lawsuit. Compliance programs provide mechanisms for employees to report issues internally. A compliance program is an advantage if your practice is targeted by the government . You may avoid being charged with a crime and be exempted from federal health care programs. If you make a mistake, you could face lighter penalties and fines.

Identifying the root causes of problems

A legal audit is the best way to identify problem areas within your practice. This audit does not only include a traditional audit of claims but also includes a legal review and analysis of operating procedures and contractual relationships. This audit is designed to find all issues that could affect compliance with regulations for government health insurance programs. While no audit can solve every problem, a legal auditor will give you an idea of how closely you have been following the law. You won't waste time or money on matters that don't relate to your practice.

First, you need to do some preliminary work before you start your review. Before you begin, determine if outside assistance is necessary. An attorney can review your written policies and procedures, as well as any contracts with vendors or potential patient referral relationships. A lawyer's assistance can provide some protection from potentially damaging evidence being released in an investigation. Other privileges don't protect evidence you discover yourself. Consulting in documentation and coding is a good option to help you review your claims and make sure that your documentation supports the medical necessity. You can also hire your own staff if they are qualified and able to devote the time.

Next, you should decide if an extensive review is necessary. A limited review might be sufficient if your practice is well managed and your billing and coding practices are very conservative. If you aren't paying enough attention to compliance, a more thorough legal audit may be necessary. You may need to document the areas that you have chosen not to address because you lack the resources or staff. Prepare a written statement stating that you haven’t found any evidence of noncompliance in these areas.

Conducting the legal auditor

An audit should include a review and analysis of all documentation and claims. To reflect the nature and scope of your practice, you should pull a random sample from your claims. You will need to work with your staff to review as much of the claims and supporting documentation as possible to get a real picture of your compliance profile.

It may be beneficial to concentrate the review on specific issues. If you are concerned about compliance with E/M documentation guidelines (either versions), make sure to include in your audit sample large numbers of records that relate to E/M services. Also, ensure that these records include the E/M codes that your physicians use the most often. You may also want to interview any nurses, physicians or other staff involved in the medical record to find out what services they provided and who was responsible for them.

Retroactive claims audits can be a great way to check how well you have managed your documentation, coding, and billing. However they raise the question of overpayments. Refusing to pay an overpayment could be considered a criminal act. If you discover fraud or ignore problems that could otherwise be mistakenly considered to be one-time errors, your practice could be subject to severe penalties. These issues may require legal advice.

An audit should include a review and analysis of your legal contracts to ensure compliance with Stark and anti–kickback laws. This is something you may need to do. Examine all contracts of your doctors that relate to the provision of medical care through the practice.

All agreements that involve the provision of equipment and space;

All employment agreements between doctors and officers, directors, and other key employees of a practice.

Contracts with hospitals and pain centers, labs, and other ancillary-service suppliers

Contracts with suppliers, independent contractors, and other providers professional services

Contracts with billing companies and practice-management consultants

Referral agreements written with other practices

You should review your contract to ensure that the arrangements for reassigning benefit don't violate Medicare regulations. These regulations state that Medicare cannot pay amounts due to a provider to anyone under power of attorney, assignment, or any other direct payment arrangement. If the other requirements are met, a billing agent can receive Medicare payments on behalf a physician. However, the agent must not convert the payments to his own control before passing them on to the physician. If you have reassigned your right to Medicare payments to a billing agency, make sure that the payments are not being forwarded to the bank account of the practice for deposit.

You should also review a list containing information about other entities in which practice owners own an investment or ownership interest, as well as the names of any people who are related to the entities with whom the practice contracts or employs them. You should ensure that your review includes both oral and written agreements. If they are not, you should formalize them.

Another issue is whether or not to waive copayments and/or deductibles for Medicare beneficiaries and Medicaid beneficiaries. This is also known as "insurance-only billing" and could be considered illegal patient solicitation. The practice could be penalized civilly if the patients are not indigent. Federal law may also prohibit professional-courtesy waivers, which allow for the waiving of co-payments and deductibles for physicians who are part of the practice as well as their families. This problem can be avoided by establishing a system where other doctors and their families are exempted from these payments in return for volunteering their time to the practice.

Review your marketing strategies, including the discounts that you offer. While some marketing tricks (such as transportation to preventive healthcare services and child-safety devices) may be permissible, others (such a health-club membership, non-prescription vitamins, and beauty aids), may not. According to the OIG's proposed regulation, any nominal incentives to beneficiaries must be used to promote preventive care and not general health and well-being. This is an extremely fine line.

The development of a compliance program

The results of your legal audit will help you determine where to focus your compliance efforts. Once you have identified your risk areas, it's time to start developing a program for managing them.

The U.S. Federal Sentencing guidelines for organizations is one of the common traits that compliance plans have in common. These guidelines specify the components that a corporate entity (which can include a personal company) must have in its regulatory compliance plan to be eligible for a reduced criminal sentence in case of prosecution. These elements are important because the OIG adopted them as essential components of a successful compliance plan. The OIG has adopted these elements as a part of a compliance program for practices. It should include written standards, education and training of all staff members, monitoring and auditing of operations, background checks of staff, and a system to report suspicious conduct.

The OIG also stated that a paper-based compliance plan is not enough. It must be designed , implemented, and enforced in a manner that detects and prevents criminal conduct. If you are being investigated, a paper program will not offer any protection to your practice.

The sentencing guidelines are only a guideline for a good compliance program. These are some practical suggestions to help you create and implement one in your own practice. (Keep in mind, that depending on your practice's size and the severity of the issues your audit uncovers, you might need to hire an attorney to help design your compliance program.

High-ranking decision makers. A compliance officer should lead your program, and perhaps a committee of 10 or more physicians. A compliance officer in a small practice may be one of the doctors or the practice administrator. This assumes that the administrator has the authority to make changes. You may need to hire someone if your practice is big. This person must be highly qualified and have access to the top management, or. This will help give credibility to the program and ensure that necessary changes are made.

The compliance officer/committee's primary duties are to supervise the legal audit and implement sentencing guidelines. They also serve as the point of contact for suspicious behavior reports and questions about internal policies. The committee or compliance officer must also keep up to date with changes in CPT codes and directives from carriers, as well as other relevant rules and regulations.

Written guidelines for conduct. Written standards should be developed that clearly state that the practice is committed ethically and that the program was established to reflect the integrity of those involved. You should also review and amend your policies and procedures in order to demonstrate compliance with the law. To avoid double-reimbursement for the same service, you may need to create a process for labeling resubmitted claim as such.

Training and education. Communication and training. To notify everyone of any changes to your policies and procedures, send out newsletters or E-mails.

The law-following training should be continuous and tailored to the specific needs of physicians, midlevel staff and support personnel. There are many options for training programs, including video presentations and seminars. To assess the level of understanding among staff, you can also use questionnaires. You can be creative with your training and make sure it is easy to understand. Don't be afraid to give examples of unacceptable behavior. Training for billing staff may include discussion about how claims submitted based on codes that do not reflect actual services provided is against the compliance plan. This could be a violation of the law.

Keep a list of people who attended training sessions and keep copies of all training materials. You will need to be able show the staff what they were taught and proof that they attended training if you are being investigated.