Ray Foxworth, D.C., FICC, MCS-P

Implementing a compliance plan in your office can feel overwhelming. I know providers who have purchased multiple compliance manuals from different consultants. These sat in the corner of their offices collecting dust waiting on their owners to rustle up enough energy to review the process of getting started. I know the feeling. When I have multiple tasks in front of me, I feel paralyzed. Better understanding the steps involved can go a long way toward making implementation of a program in your practice easier.

Why should you even implement a compliance program in your practice? The penalties for health care fraud and abuse are significant and can include criminal prosecution, civil money penalties, and possible exclusion from federal healthcare programs. However, penalties for provider offices that have a compliance program in place may not be as significant. Additionally, a compliance program can help minimize billing mistakes, increase revenue, and improve the quality of patient care. And most importantly, IF you are audited and have an active compliance plan in place, it shows you are at least making the effort to do things the right way versus “knowingly and willfully” ignoring the importance of compliance.

If you are audited and you do NOT have a plan in place or are not actively following it, you are like the driver doing 85 in a 75 mile-per-hour speed zone with a radar detector. You are “knowing and willfully” speeding. And don’t think for a moment that Trooper Jones doesn’t see those two little circles where the suction cups were holding your radar detector in place. Yes, confession is good for the soul, and I have received “driving awards” myself. Some call them tickets, I prefer awards! The Office of Inspector General (OIG) offers 7 steps for creating a compliance program for small physician and group practices.

1. Auditing and Monitoring: To have a successful compliance plan, you must be able to show that the plan is actually improving compliance in your office. To start, review the OIG Work Plan and identify any areas of concern for your practice. In October 2017, the Office of Audit Services indicated they would continue to review Medicare Part B payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements. This indicates that all chiropractic offices should audit and monitor Medicare Part B claims for services to be sure that they meet the Medicare requirements for payment.

To determine if there are areas of billing and coding that are not in compliance or need improvement, you will need to conduct a baseline audit. Your baseline audit should determine if claims are accurately coded, documentation is correct and completed in a timely manner, services or items provided are reasonable and necessary per payment guidelines, and inappropriate incentives or discounts do not exist. A basic guide on the number of medical records to audit is five medical records per payer or five to ten records per physician.

Audits should be completed and documented in the compliance plan annually. If your baseline audit identifies areas of concern, then reviews of these problem areas should be conducted more frequently until the issues are corrected. If you are uncomfortable in performing the initial baseline audit, or you are feeling overwhelmed by the audit process, it may be wise to hire a consultant to conduct the initial audit. Reports from consultants will be detailed and outline areas of concern and how to improve.

2. Practice Standards and Procedures: Once you have the results of your initial audit and have identified areas of risk, you will need to develop a method for minimizing those risks. A good place to start is by updating your practice’s policies and procedures. When updating or writing your policies and procedures, make sure they are concise and easy to read, understand, and follow. I cannot stress enough the importance of not typing up a bunch of laws and regulations that are confusing and hard-to-follow. Giving your team an outline of expected behaviors and job expectations will go a long way in increasing productivity and job satisfaction. Policies and procedures should, at a minimum, address prevention of inappropriate conduct in the areas of billing, coding, documentation, inducements, and kickbacks.

3. Designate a Compliance Officer: Many consultants recommend that the provider select someone other than themselves to act as the compliance officer for the practice. In smaller practices, you can also elect a compliance committee made up of two or more employees who each take charge of managing and implementing the compliance plan. For example, you might have one employee responsible for internal auditing, another for implementing the training program and verifying current employees are not listed on the OIG exclusions list, etc. A job description should be written for the compliance officer in addition to their other duties in the office.

4. Conduct Appropriate Training and Education: All new employees should be trained on the overall compliance program immediately after they are hired. Training should be provided for all staff annually. In-person (seminars/conventions) and/or webinar training is sufficient as long as it is documented in the compliance manual. It is a good idea to allocate 15 minutes of your weekly staff meetings to go over compliance training. Keep in mind that some staff members will need additional, specialized training depending on their roles in the office. For example, billing/insurance staff members should complete training that is specific to coding and billing requirements. Compliance officers should complete additional training to aid in their roles. A certificate of completion for online and in-person training is sufficient proof of attendance. For staff meetings, have a sign-in sheet with the date, compliance topic discussed, and the length of time it was discussed.

5. Respond Appropriately to Detected Violations: As part of your policies and procedures, you should address how detected violations should be reported and investigated. If a violation has taken place, a written plan of action should be outlined to correct the problem. This could include clarification on a rule or regulation, a change of policy, or issue of a refund to a payer. The person who investigated the violation should be documented along with the findings of their investigation. The severity of the violation may require that the person involved be retrained, disciplined, or terminated. In cases where a potential criminal violation has taken place, or a violation that requires self-disclosure to a law enforcement or government agency, you may require the assistance of a healthcare attorney or consultant.

6. Develop Open Lines of Communication: There should be written confidentiality and non-retaliation policies included in your compliance program. Employees should feel comfortable asking questions, asking for clarification, and reporting concerns. It is beneficial to publish (for patients and employees) the various ways to communicate with the compliance officer. E-mail, telephone, in writing, and in person, are all acceptable ways to report and discuss areas of compliance.

7. Enforce Disciplinary Standards through Well-Publicized Guidelines: A written policy should be included in your policies and procedures that outlines actions for inappropriate conduct or failure to follow the practice’s policies and procedures. The policy should clearly state what is considered non-compliant and who is responsible for taking appropriate action. Levels of non-compliance include intentional disregard for policies and procedures, failure to detect a violation, and failure to report a violation. Disciplinary actions should also be clearly defined by using examples.

Establishing a compliance program in your office can seem daunting at first, but it starts with updating current policies and procedures, establishing and documenting training, and initiating a baseline audit to see what areas may need improvement. If you are currently attending webinars on our weekly webinar series, just print off the certificate of completion and place it in your training manual, or create a sign-in sheet and watch it as a team. Being compliant is much easier than you think. Once you get started, you may find yourself wondering what you were so worried about. To view a list of our upcoming webinars, click here.