On June 12, 2000, the Department of Health and Human Services' Office of Inspector General ("OIG") issued a draft guidance document -- Compliance Program Guidance for Individual and Small Group Physician Practices ("Compliance Program"). The Compliance Program has a 45-day comment period. The OIG plans to publish the final version of the Compliance Program later this year.
The Compliance Program is not a one-size-fits-all approach. The Compliance Program is a set of guidelines, a blueprint for action, that physician practices should consider when developing and implementing a compliance plan. The OIG recognized that many small physician practices (the term "small" is not defined) may not have the resources to implement a full-blown compliance plan. However, the OIG noted that all physician practices, regardless of size, must have appropriate compliance policies in place and be sure their employees are aware of the policies and their respective responsibilities. The Compliance Program does not, unfortunately, delineate what framework the OIG considers to be adequate.
In other respects, the Compliance Program is similar to other guidance documents already issued by the OIG for clinical laboratories, hospitals, home health agencies, third-party medical billing companies, durable medical equipment suppliers, hospices, Medicare+Choice plans and nursing facilities.
The Compliance Program is based upon the following seven elements:
- implementation of written policies and standards of conduct;
- designation of a compliance officer or contact;
- development of training and education programs;
- creation of accessible lines of communication to keep practice employees updated about compliance activities;
- performance of internal audits to monitor compliance;
- enforcement of standards through well-publicized disciplinary directives; and
- prompt corrective action to detected offenses.
The Compliance Program identifies specific risk areas for physicians, including coding and billing; the provision of reasonable and necessary services; timely, accurate and complete documentation; and improper inducements, kickbacks and self-referrals.
According to the OIG, the benefits of a well-structured compliance plan include:
- the development of effective internal procedures to ensure compliance with regulations, payment policies and coding rules;
- improved medical record documentation;
- improved education for practice employees;
- reduction in the denial of claims;
- more streamlined practice operations through better communication and more comprehensive policies;
- the avoidance of potential liability arising from noncompliance; and
- reduced exposure to penalties.
One of the major goals of instituting a compliance plan is to prevent a physician practice from violating the civil False Claims Act. The False Claims Act is directed at actions that are committed with actual knowledge of the falsity of the claim, reckless disregard, or deliberate ignorance of the falsity of the claim. According to the OIG, the commitment to a compliance program goes beyond the mere existence of written policies and procedures. It is a philosophical approach and everyone in the practice - physicians and support staff -- should understand the obligation to comply with the compliance program and make sure its goals are upheld.
Once a compliance plan is adopted by the practice, the practice's work is not done. In fact, it is really just the beginning. Everyone in the practice should receive initial and continued training regarding the compliance plan. This training has two goals: (1) all employees should receive training on how to perform their jobs in compliance with the standards of the practice; and (2) each employee should understand that compliance is a condition of continued employment. There needs to be periodic billing audits to ensure accuracy.
Physicians must remember that they are responsible to the Medicare program for bills sent in the physician's name or containing the physician's signature, even if the physician had no actual knowledge of a billing impropriety. The attestation on the HCFA 1500 form, i.e., the physician's signature line, states that the physician's services were billed properly.
The OIG suggested that physician practices should view the implementation of an effective compliance plan as comparable to a form of preventive medicine to protect against fraudulent or erroneous conduct. While the development of a compliance plan may seem like a difficult or unnecessary pill to swallow for some physician practices, there are long and short term benefits because the OIG, understandably, believes that all health care providers have a duty to reasonably ensure that their claims submitted to Medicare and other Federal health care programs are true and accurate.
The development of an effective compliance plan tailored to each physician's practice resources will reduce the possibility of fraudulent activity through a coordinated effort and provide the physician's practice with a greater degree of accountability and ability to self-check their actions.
For further information or assistance, please contact Bruce D. Armon or John B. Reiss.
The Health Law Department consists of 15 lawyers who represent a wide diversity of healthcare providers, including general and specialty hospitals and hospital chains, a variety of outpatient facilities, managed care providers, entrepreneurial companies, physicians and physician groups in all types of specialties, a very large physician clinic, and numerous physician joint ventures.