| It is dangerous to assume that because your
practice is small that you don't need to have a healthcare compliance program. Any
healthcare practice can become the target of a fraud investigation!
With just 7 easy steps, you can create a bona fide
healthcare compliance program that will keep you and your practice safe…
Step 1: Assess the areas of your practice that pose
the greatest liabilities.
To determine this, you will need to consider the following:
- Do you provide healthcare to patients who are either
employees of the Federal Government who will be filing claims against/with their
employers' carrier, or who will be filing claims under a government contract (e.g.,
Medicare/ Medicaid)?
- Do you accept Letters of Protection on 3rd-party liability
claims?
- Do you have high employee turnover?
- Do you file your billing electronically?
- Do you out-source your collections?
- Do you contract with independent practitioners?
- Do you contract with outside vendors?
- Have any of your providers been sued for malpractice?
- What percentage of your billings are denied/reduced?
- Do you have a mechanism for responding to either denials or
reductions in reimbursement?
- Do you provide ongoing training to billing and collections
employees regarding CPT coding and ICD-9 coding?
- Do you perform background investigations on all employees
prior to hire?
- Do you provide a mechanism for reporting complaints for
internal resolution?
Step 2: Develop policies and procedures to allow
management of each potential liability.
To develop healthcare compliance policies and procedures,
create a Compliance Manual that addresses areas of exposure to which attention must be
directed to lessen the exposure arising in each area. This is one of the most critical
areas of any compliance program, and should not be given short-shrift.
You will also want to create an Employee Manual that lists
employees' duties and responsibilities. It is recommended that the manual be tailored to
your individual practice.
Step 3: Delegation of Duties:
Appoint a Compliance Officer who is qualified to oversee a
healthcare compliance program. Role. The individual appointed must be someone who refuses
to compromise the quality and integrity of the compliance program. Policies pertaining to
billing, coding, documentation, etc. should be viewed as mandatory, not optional!
Step 4: Create a Compliance Committee:
Determine what departments within your practice should be
represented on a Compliance Committee that your Compliance Officer will report to.
Frequently, providers mistakenly conclude that the practice consists of only one
department. Rarely would this be the case.
Most practices will have, if nothing else, the following:
- Record keeping;
- Billing
- Collections
- Production.
Although one individual may wear hats for each department,
it is best to consider these departments as discrete entities. This permits more effective
management and analysis of your overall practice.
Step 5: Design Hotline Protocol
This protocol should be effective in providing a reporting
mechanism for concerns/complaints arising either internally (i.e., employees) or
externally (e.g., patients, insurance adjusters et al.).
Step 6: Educate Your Employees on Correct
Healthcare Compliance Policies and Procedures
The policies/procedures contained in your healthcare
compliance manual serve as an excellent educational tool for all employees and agents.
However, to be effective, it is necessary for those policies and procedures to animate
those with whom they are shared. Merely having a dormant document in which such policies/
procedures are contained will not accomplish your intended goal of developing a vibrant
bona fide healthcare compliance program.
You need to set a time and place for training session(s).
It is important to conduct training in a manner most likely to capture the largest number
of employees/agents for which the training is intended.
Step 7: Set Up Disciplinary Procedures
Setup disciplinary procedures to ensure licensed providers
y are the individuals to whom boards of examiners will look for accountability. They are
the ones law enforcement will look at as the instigator of abusive and unnecessary
procedures. And, they are the ones governmental agencies will address inquiries into
questionable/unusual practices.
Unlicensed individuals must realize that their activities
may also result in the accrual of personal criminal liability. Neither licensed nor
unlicensed individuals are immune from prosecution. I was involved in one investigation in
which a provider whose name was affixed to billing statements had been dead for more than
six months. The office manager's sentence was actually longer than the doctors'. |
