Healthcare Compliance Program

The Affordable Care Act requires any healthcare provider who participates in the Medicare and Medicaid programs to implement a Compliance Program.  Since 2000, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) had recommended all individual physicians and small group physician practices to create a voluntary Compliance Program for the practice. Now that the Affordable Care Act mandates a Compliance Program, all healthcare providers should have one. The Martin Law Firm also have extensive experience on healthcare compliance for chiropractors:

 

What is a Healthcare Compliance Program?

A healthcare Compliance Program is a detailed, comprehensive written guide that establishes policies and procedures for helping the individual physician or the practice reach compliance objectives.  An effective Compliance Program should be tailored to a particular type of provider, i.e. medical doctor, physical therapist, chiropractor, etc. and it should identify risk areas for billing, coding and documentation as well as setting forth essential elements that the OIG has already established.

 

What are Risk Areas for Billing, Coding, and Documentation?

Insurance and CMS audits and post-payment reviews are rampant.  When providers fail to comply with billing, coding and documentation requirements, the insurance payers or CMS will attempt to recoup from the provider payments already made for particular services.  For example, if a provider fails to properly document why services are medically necessary, then an audit could lead to denials of all services that are considered maintenance.  An effective compliance program will, among other things, identify the definition of medical necessity and then provide further description as to how to properly document it.  This may include a comprehensive framework for establishing a treatment plan, SOAP notes, examinations and re-examinations.

 

Does a Compliance Program Change Depending on the Provider Type?

Yes. An effective Compliance Program should be specific for each provider type and the specific healthcare services being provided.  For example, a medical doctor who specializes in pain management should have a compliance program that provides comprehensive information on billing, coding and documentation requirements for injection.  A chiropractor should have a compliance program that provides information on proper use of CMT codes.

 

What Else Should a Compliance Program Include?

The OIG established seven (7) essential elements that should be included in any compliance program.  The 7 elements are topics that must be further developed by the provider or the practice.  The provider or practice should develop policies and procedures for 1) self -auditing and monitoring, 2) identifying and establishing compliance standards, 3) naming a compliance officer and establishing the compliance officer’s duties and responsibilities, 4) training and educating employees, contractors and staff, 5) implementing corrective action plans if non-compliance is discovered, 6) developing lines of communication within the practice, and 7) developing and enforcing disciplinary standards.

 

What are the Benefits of a Compliance Program?

If a healthcare provider properly develops, maintains and adheres to a Compliance Program, then the provider will reduce his or her risk for violating Medicare, Medicaid and insurance payer rules and guidelines for billing, coding and documentation.  By reducing the risk of a violation, the healthcare provider can usually avoid the audit or post payment review, which, in turn will lower the chances of having to return any overpayments.  Even when a provider faces an audit or post payment review, the provider will mitigate his or her risk exposure if the provider has implemented and followed the compliance program guidance.

 

Healthcare Compliance Law Firm

The Martin Law Firm has been preparing and implementing Compliance Programs for healthcare providers for over a decade. The Martin Law Firm also works with healthcare compliance consultants and coding experts to provide a comprehensive pathway for the healthcare provider to reach the compliance objectives. Contact The Martin Law Firm today at 215-646-3980 to speak with a healthcare compliance attorney.