Within the world of healthcare, compliance is an important component. Viewed as “preventive medicine,” its purpose is to identify small problems before they become big ones, enabling an organization or practice to correct deficiencies before they are discovered by auditors. Rather than waiting until problems start to get out of control and regulatory agencies begin to impose penalties and possibly fines, it’s best to hire the services of a healthcare compliance programs lawyer. By doing so, you can be proactive in correcting deficiencies and ensuring your practice will be leading the way in patient care as well as compliance.
By identifying the appreciable risks within a practice or organization, the chances of committing costly mistakes can be greatly reduced. As a compliance plan is developed and then implemented, practical policies and procedures can be put in place throughout each department. As a result, staff can be better trained through continuing education programs and workshops. In most cases, policies and procedures tend to focus on such important matters as billing, documentation, and the requirements of Medicare and other third-party providers and payors.
Due to the compliance process being so complex, it’a virtually inevitable that legal dilemmas will occur. When this happens, it’s more important than ever to consult with a healthcare compliance lawyer before things begin to unravel. One of the most common problems practices and organizations face revolve around the False Claims Act. With numerous timely amendments having been made to it in recent years, practices face additional obligations when it comes to repaying identified overpayments. With various legal requirements surrounding the identification of overpayments, a knowledgeable healthcare compliance programs lawyer can guide a practice or organization through the complicated process of determining how and when to carry out repayments.
Essential Elements of a Compliance Program
Even though compliance programs are largely voluntary for practices and organizations, they nevertheless need to possess certain elements to be successful. According to the U.S. Department of Health and Human Services, some of the most important elements include designating a compliance officer and compliance committee, conducting appropriate training and education for staff, responding quickly to offenses and taking corrective action, having open lines of communication, and enforcing disciplinary standards. By identifying the areas of a practice or organization that have the most urgent needs, it will be much easier to have key personnel gain a greater understanding of how services are provided, documented, and billed.
Who Performs Internal Compliance Audits?
To ensure an organization gets the best results during a compliance audit, it’s highly recommended that they be performed under the direct supervision of an attorney. When done in this manner, the organization or practice can have peace of mind knowing its work falls under attorney-client privilege. By being able to provide your lawyer with all initial drafts of compliance rules and regulations, you can be sure everything will be thoroughly reviewed prior to implementation. In addition to this, a lawyer can recommend the use of an outside auditor for the compliance audit. Although it’s widely acknowledged that a member of the organization or practice who has specific coding or billing knowledge could perform the audit, compliance programs lawyers know an outside auditor will provide a fresh set of eyes on matters, which can often be the key to ensuring billing is done correctly.
The Internal Reporting System
When an organization implements a compliance program, one of the most important aspects involves setting up an internal reporting system. Examples of this can include a hotline, suggestion box, or other means of confidential communication. In most organizations that conduct employee training sessions, all who attend usually sign statements agreeing to report all compliance matters. While this may not sound important at first, the fact is it provides significant legal protection for the practice, since employees are required to bring compliance matters to the internal compliance officer rather than to an outside entity.
While healthcare compliance rules and regulations can be some of the most complex of any industry, it is crucial to ensure your practice is abiding by all of them in a professional manner. By working with a healthcare compliance programs lawyer, the chances of making critical mistakes lessens tremendously.
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The concept of healthcare compliance programs began in 1997 with a publication by the Office of Inspector General (OIG) within the US Department of Health and Human Services (HHS). That first program was designed for individuals and small group physician practices. Since that time, there have been an entire series of HHS OIG compliance guidelines addressing other segments of the health care industry that includes: nursing facilities, HHS research grants and awards, hospitals, pharmaceutical firms, ambulance providers, hospices, home health agencies, clinical laboratories, third-party medical billing firms, and providers of medical supplies and equipment.
The Affordable Care Act mandated additional corporate healthcare compliance programs in 2010 for Medicaid and Medicare providers. The essence of this compliance program requires any Medicaid provider receiving $5+ million annually in payments have mandatory written policies that affect all employees and certain types of vendors regarding state and federal violation of anti-fraud laws, whistle blowers legal protections, and all policies addressing fraud detection and prevention. A well-defined compliance program is a prerequisite for Medicare and Medicaid participation.
Healthcare compliance programs are the guidelines for efficient internal controls that are governed by private, state, and federal health plans. Most compliance programs are still voluntary, but compliance programs are mandatory for participation in Medicaid and Medicare plans. However, the development of either a voluntary or a mandatory program will enhance the detection, prevention, and resolution of circumstances and situations that do not conform to legal health care requirements as well as ethical and business practices. An effective program needs to contain benchmarks for implementation and achievements that meet federal and state laws as well as the expectations of industry regulators.
The HHS OIG has developed a list of seven core elements that every healthcare compliance program needs to address. They are:
1. Implementation of procedures, policies, and conduct standards
2. Designation of a compliance officer and committee to monitor the efforts and the enforcement of practice standards
3. Institute training and education sessions on compliance procedures, policies, and conduct standards
4. Development of effective communication lines with staff personnel that includes anonymous reporting avenues
5. Use of periodic self-audits to conduct internal monitoring and auditing
6. Enforcement of employee standards using well publicized disciplinary guidelines
7. Prompt response when discovering offenses and the development of corrective action plans
The HHS OIG has published a directory of recommended compliance program guidance documents that can be viewed at http://oig.hhs.org/compliance/compliance-guidance/index.asp.
The healthcare community is experiencing an environment of ever increasing regulations and enforcement. A strong, enforceable compliance program is a positive, protective tool that ensures adherence with all laws and regulations that govern a specific practice. A well-structured program enables a provider to isolate and correct any deficiencies before they can negatively impact a practice. Consultation with a professional, experienced healthcare lawyer will enlighten healthcare providers on the development and implementation of compliance programs that addresses their specific needs and provides them with real protection aimed at minimizing, or eliminating, any potential risks within their particular practices.
A program that is finely tuned and followed is no guarantee that a practice will never be investigated. However, in the event that there is an investigation, having a solid compliance program, with all of the supporting documentation, demonstrates a provider’s commitment to patient safety, violation avoidance, and full adherence to all governing healthcare laws, policies, and regulations. An active compliance program improves the provider’s chances of having a violation viewed as an accidental, one-time, occurrence rather than evidence of a pattern of fraud.
Government and private sector payors are consistently concerned with the rising cost of health care and have increased their attention on finding and eliminating fraud, waste and abuse. The result of this intensity is an enormous rise in the number of audits related to Medicaid, Medicare, and third party payors. Any confirmed violations involving fraud will result in a practice or service be excluded from Medicaid and Medicare participation. A finding of fraud can also result in high fines, potential loss of professional licenses, and possible prison time. Any provider facing compliance audit investigations will need specialized healthcare audit lawyers. Our experienced attorneys help our clients with their defense against alleged compliance investigation audits.
Our health care lawyers work with providers in structuring business compliance programs that meet healthcare practice goals while staying current with all up-to-date federal and state laws, rules, and regulations. We not only work for our clients, we stand with our clients when representation is required.
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