How to Reasonably & Effectively Implement Compliance Programs for Small Group Physician Practices Andrea Merritt, Director of Compliance & Audit Services Ashlie Heald, Compliance Specialist Nova Compliance Group, a Hall Render Company Presentation Overview Why should I have a Compliance Program? Scope Benefits How do I build and maintain a Compliance Program? Approach Components Tools Discussion/Group Activity Compliance Program - Scope OIG Guidance on Compliance Program for Individual & Small Group Physician Practices Focuses on voluntary measures related to claims submitted to Federal health care programs Program measures may also apply to private payor claims, if desired Recognizes limited financial and staff resources Encourages providers to be proactive about preventing and detecting fraud, waste and abuse 1
Compliance Program - Benefits Prevention of erroneous claim submissions Prevention and detection of fraudulent conduct Improvement of business operations Optimization of proper payment of claims Minimization of billing errors Reduction of audit chances Avoidance of conflicts with Stark and Anti-Kickback statutes Enhancement of patient care Demonstration to practice s employees of commitment to ethical conduct Building the Program Build a compliance program based on the financial and staffing resources available to you Extent of implementation dependent upon size and resources of the practice Step-by-step approach recommended for developing and implementing a compliance program to fit the needs of the practice Identify risk areas within your practice that have been problematic and use those as a starting point Erroneous vs. Fraudulent Claims OIG realizes majority of physicians are working ethically to render high quality care and submit proper claims Physicians are not subject to penalties for innocent errors, or even negligence False Claims Act primary enforcement tool Actual knowledge of the falsity of the claim, reckless disregard, or deliberate ignorance Criminal Penalties Criminal intent to defraud proved beyond a reasonable doubt 2
Erroneous Claims Without penalties Absent a violation of a civil, criminal, or administrative law, erroneous claims result ONLY in the return of funds claimed in error. Be proactive! Audit claims, provide coding and documentation education, and return funds when deemed appropriate. Compliance Program Components The seven components are the basic building blocks of a compliance program. Unlike guidance for larger providers, OIG guidance for physicians addresses specific concerns for a smaller organization. Compliance Program Components Seven components: 1. Internal auditing and monitoring 2. Compliance and practice standards 3. Compliance officer or contact 4. Compliance training and education 5. Response to detected offenses and development of corrective action 6. Open lines of communication 7. Enforcement of disciplinary standards through well-publicized guidelines 3
Auditing and Monitoring Ongoing evaluation process to determine whether: Individuals are carrying out their responsibilities Claims are submitted appropriately Two types of reviews: Standards and procedures review Claims submission audit Practice Standards & Procedures OIG identified 4 areas for physician practices to be used as a starting point in assessing potential risks: 1. Coding & billing 2. Reasonable & necessary services 3. Documentation 4. Improper inducements, kickbacks and selfreferrals Based on identified risk areas, develop written standards and procedures to address those areas Update clinical forms periodically to ensure clear and complete documentation of clinical care Standards & Procedures (cont.) OIG recommends creating a resource manual or compliance binder Communicate standards and procedures to all employees: At new hire At issuance of new or revised standard or procedure 4
Compliance Officer/Contact Member of the practice staff who is responsible for: Development of corrective action plan(s), in needed Oversight of adherence to the plan Compliance Officer/Contact can either be responsible for: All compliance activities, or Limited involvement to resolve current issues Due to resource constraints, a physician practice may designate more than one person with compliance responsibilities Compliance Officer (cont.) Compliance Officer/Contact(s) duties may include: Monitoring and oversight of program implementation Establishing methods to: o Improve efficiency and quality of services o Reduce vulnerability to fraud and abuse Reviewing and revising the program as the laws, regulations, and/or needs of the practice change Maintaining a focused training program Ensuring screening against relevant excluded providers lists for all employees, medical staff, and independent contractors Investigating any reports or allegations of unethical or improper conduct and monitoring subsequent corrective action Education and Training Develop a plan for education and training by determining: Who needs training Best type of training based on the practice When and how often training is provided Compliance training may include: Importance of the compliance program and the individual s role in compliance Practice standards and procedures and the consequences of violations Explain why the practice is implementing a compliance program and emphasize the benefits of a compliance program 5
Responding to Detected Offenses & Developing Corrective Action Important to follow up on reports of suspected compliance violations If a violation has occurred, steps should be taken to correct the problem Use of monitors and indicators, such as: Significant changes in the number/types of claim rejections Challenges to medical necessity or validity of claim Unusual changes in code utilization Provisions in practices standards and procedures for handling individual misconduct Lines of Communication Open Door policy Reporting requirement User-friendly reporting, such as anonymous drop box Procedure for processing reports Utilizing process that protects anonymity Non-retaliation/Nonretribution policy Enforcing Disciplinary Standards Well-publicized guidelines and consistent enforcement add credibility and integrity to a compliance program Practice standards should include disciplinary measures for failure to detect or report suspected violations Enforcement and disciplinary procedures should be consistent, yet flexible 6
Compliance Program Tools Development, Implementation and Maintenance Risk Assessment Practice-specific areas of risk OIG Work Plan Audit Plan Compliance Plan Standards of Conduct Policies and Procedures Compliance Logs Compliance Implementation Education & Training Corrective Action Compliance Effectiveness Assessing the effectiveness of a compliance program is an ongoing effort Three types of audits are recommended: baseline audits (initial audits) proactive audits (these can be based on the risk areas identified in the OIG's compliance program guidance or Special Fraud Alerts) issue-based (when the provider knows there is a problem and is trying to ascertain the depth of the problem) Organizational Structure Options: One member of the physician practice would oversee compliance and implementation of action plans. Due to staffing constraints, more than one person can be responsible for compliance Compliance liaison with outsourced compliance support 7
Alternative Structures Participate in other provider s compliance programs Hospital Physician management companies Collaborate Avoiding conflicts Ensure that compliance services are not provided by a sponsoring organization for free. Group Discussion Questions? 8
Andrea Merritt Director of Compliance and Audit Services Ph: 248-457-7858 Email: AMerritt@NovaCompliance.com Ashlie Heald Compliance Specialist Ph: 248-457-7805 Email: AHeald@NovaCompliance.com 9