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I've Got a Compliance Plan, Now What? Current Compliance Issues for Medical Practices

Ensuring the success of a medical practice requires a targeted focus on multiple areas. Aside from matters involving patient care, administrative efficiency, and amassing a team of qualified and skilled professionals, medical practices must also concern themselves with regulatory compliance. In an area as complex as health care and an era when providers face tremendous scrutiny from regulators, ensuring compliance is no easy task. However, it can be done efficiently with the assistance of experienced attorneys who know how to help providers navigate through an increasingly complex regulatory landscape.

At Hendershot, Cannon & Hisey, P.C., we frequently blog on important issues faced by health care providers throughout Texas and the U.S., and have drawn from our extensive experience representing physicians and medical practices to discuss matters related to regulatory compliance.

While many of our health and medical law blogs drill down into particular concerns, unique laws, and various issues involved in the practice of medicine, they generally focus on the comprehensive need for making compliance a priority. To achieve this, medical practices should always have effective compliance plans. As we see first-hand, however, having a compliance plan alone does not necessarily ensure compliance, nor does it mean that the most important compliance issues are addressed effectively.

7 Important Compliance Issues for Medical Practices

Proactive compliance plans can be the first line of defense when it comes to crime prevention, enforcement of government rules and regulations, and quality care for patients. While they may differ based on the specific needs of practices, they are always crucial to protecting practices against common violations and issues that can result in costly or time-consuming audits, investigations, or harshly penalized violations involving improper payments, fraud and abuse, and other areas of liability. While physicians and medical group practices must establish compliance programs as a condition or Medicare enrollment, or participation with certain commercial insurance plans, ensuring effectiveness is an entirely separate matter.

Below, we discuss a few of the most important issues medical practices should address in terms of their compliance plans:

1. Auditing & Monitoring – Promoting a commitment to compliance requires the establishment and implementation of policies and procedures that enable practices to ensure compliance on an ongoing basis. This includes active auditing and monitoring to evaluate standards and procedures for their accuracy and compliance. For example, medical practice compliance plans should:

  • Outline general audit guidelines, including procedures for reviewing compliance with coding, billing, and documentation requirements, on a concurrent (prior to submission) and / or retrospective (after submission) basis
  • Prioritize federal programs when conducting audits and monitoring, and stay up to day with any changes in claims submission, OIG updates, and compliance guidelines.
  • Compare audit results with benchmark data
  • Establish guidelines to foster collaboration between at least one medically trained individual (i.e. nurse or physician) and administrative personnel
  • Conduct audits at least one per year, and review at least five or more medical records per federal payer, and 5 to 10 medical records per physician

2. Establish Standards – Medical practice compliance plans need to also address how any changes or issues identifying in audits can be made. Practices should create standards for updating clinical forms clearly and completely, and should address all aspects of daily operations, including data capture, patient flow, and billing processes. This may entail

  • Building on existing policies to create standards for compliance updates;
  • Using a third party’s compliance standards as a basis for standards, and tailoring to the unique needs of the practice
  • Structure standards in accordance to the OIG’s identified risk areas where noncompliance commonly occurs, including coding and billing, necessary and reasonable services, documents, and improper inducements, self-referrals, or kickbacks.

3. Designating a Compliance Officer – Medical practices should identify and appoint an individual to serve as a compliance officer, who will be responsible for leading compliance efforts and enforcing standards established by the practice. While smaller practices may not need the same level of oversight, designating a compliance officer, or someone in charge of compliance efforts, can add a layer of accountability for addressing risks and enacting corrective actions. These individuals should be selected for their experience in medical billing, attention to detail, and communication skills. Practices may also consider outsourcing the role of a compliance officer, particularly when smaller practices may not be able to justify a full-time position or require more experienced personnel than what is available within the practice.

4. Training & Education – Training and educational programs are vital to ensuring staff understand the importance of regulatory compliance and ways to ensure compliance. Such training standards can become part of the compliance plan and overseen by a designated compliance officer. As advised by the OIG, medical practices should focus on two primary objectives in relation to compliance training:

  1. Training all employees on performing job duties in compliance to both practice standards and applicable regulations; and
  2. Ensuring employees understand compliance is a condition of employment.

Practices may choose to conduct training through various means, such as through newsletters or formal training sessions, and via in-house or outsourced trainers. Compliance plans should also address the type of training needed and when (the OIG recommends annual training sessions and training upon new employment.)

5. Responsive Initiatives – Compliance plans should contain policies for responding to violations and correcting noncompliance issues. These responsive initiatives should be outlined by an enforcement plan and policies which focus on timely and thorough action, and address investigative protocol, what parties should be informed, and how corrective actions are reviewed and approved. They can also outline policies for seeking experienced legal counsel, and determining when regulators or authorities should be notified.

6. Open Lines of Communication – Communication is critical to combatting noncompliance, as it will help to prevent future problems and discuss why issues occurred in the first place. Experts recommend an “open-door policy” which creates a culture that will allow employees to feel free discussing noncompliance issues and expressing any concerns, as well as anonymous reporting.

7. Enforcement of Disciplinary Standards – Enforcement and disciplinary standards created through well-publicized guidelines are critical to adding credibility and integrity to compliance plans. This means employees need to understand consequences imposed for noncompliance, including how individuals who violate practice standards or regulations are disciplined (i.e. warnings, probation, demotion, suspension, etc.). Many medical practices achieve this through the creation of an employee handbook.

Comprehensive Counsel for Medical Practice Compliance Plans

As a law firm that has earned national recognition for our work in health care and medical law and the representation of providers facing audits, investigations, and allegations of waste, fraud, and abuse, Hendershot, Cannon & Hisey, P.C. has the requisite experience and resources to help all types of medical practices establish the clear and enforceable compliance plans that allow them to effectively operate their practices, ensure compliance, and avoid risks of litigation or penalties that can jeopardize their futures. From tailoring compliance programs to the unique needs of practices to addressing critical issues and compliance with important federal health care regulations like the Anti-Kickback Statute, Stark Law, and False Claims Act, and other Texas health care fraud laws, our team focuses on a comprehensive approach to compliance, and to the proactive measures that ensure providers establish the policies and best practices for implementing their plans moving forward.

If you would like more information about medical practice compliance plans and how our award-winning Texas health care attorneys can help you, call (713) 909-7323 or contact us online for an initial consultation.

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