Compliance Plan – A Provider’s Defense

The Office of the Inspector General (“OIG”) has always encouraged Medicare and Medicaid providers to implement a compliance program. For 14 years, as a matter of fact, OIG has provided compliance guidance in 11 healthcare sectors (including: hospitals, nursing facilities, home healthcare, hospice and third-party billers). With the passing of the Patient Protection and Affordable Care Act (“PPACA”), compliance plans and programs are now mandatory for any provider enrolled in a Federal health care program, including Medicare.

Compliance plans and programs for different health care organization will naturally vary.  However, OIG has already issued seven “core elements” that have to be present in every compliance program to participate in Federal health care programs.

• Internal Monitoring and Auditing: A regular review of the organizations claim process is necessary in demonstrating the effectiveness of the organization’s plan and ability to identify risk areas and violations.

• Written Standards and Procedures: Integral to the success of the compliance program, written standards and procedures inform the organization’s members of the compliance requirements.

• Designation of a Compliance Officer: A Compliance Officer is charged with the responsibility of overseeing the program, implementing all functions of the program and acting as the reporting member of the organization for violations or compliance concerns.

• Training and Education: All members of the organization should have effective and appropriate routine training on the standards and procedures which they are responsible for to comply with the program.

• Investigation of Alleged Violations and Appropriate Disclosures: Organizations must investigate alleged compliance violations or issues when they are discovered. If it is determined that a violation of the law or compliance program has occurred, action must be taken immediately to remedy the situation. Return of overpayment, internal discipline, or civil or criminal action may be necessary depending on the violation.

• Open Lines of Communication: Organization members must have an open line of communication, such as a “hotline,” to communicate without repercussions, compliance issues or violations.

• Enforcement of Disciplinary Standards: An organization’s members should be made aware of the disciplinary actions that will be taken in the event of failure to comply with the written standards and procedures of the compliance program. These actions should be applied consistently.

These core elements are the foundation for every compliance plan. However, every plan has to fit your specific organization, and could possibly be subject to additional requirements. Nursing facilities, for example are also subject to PPACA, Section 6102, which has eight required elements.  As well, Nursing facilities are on a rapidly approaching deadline for compliance, with all programs required to be in place by March 2013.

These core elements fall in line with the federal Sentencing Guidelines at §8B2.1, and a program that follows these guidelines can be subject to a reduced criminal sentence in the event of a violation. It is not simple to design (or re-design) and implement a plan that will protect your organization from the increased fraud, waste and abuse controls. Arrests and convictions are almost a daily occurrence, now. Preventing simple mistakes can and will make all the difference. Also having an attorney draft or review your compliance plan and program is always a smart safeguard.

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This article does not constitute legal advice.