Next at Bat for Your Practice: Compliance

The past few years in health care have been dedicated to transitioning medical practices to electronic health records and moving payer systems from the International Classification of Diseases (ICD) 9 to ICD-10 codes. Those transitions were complete in their systemic nature, which often caused practices to buckle under the pressure of the resource requirements during the shift. Now, new attention is being focused on your practice’s need for a compliance plan.

WHAT IS A COMPLIANCE PLAN?

A compliance plan is intended to prevent, detect, and correct inappropriate and even criminal actions by your providers and your team.

At the very least, compliance programs should provide clear direction on practices, policies, and conduct surrounding the Health Insurance Portability and Accountability Act for privacy and the Occupational Safety and Health Administration standards for employees’ actions. These programs also help with hiring practices, diagnostic coding, and procedural coding for medical and clinical services. In addition, they assist with confidentiality, patients’ rights, billing compliance, and medical records release.

PAYOFFS AND PENALTIES

Although compliance plans are currently voluntary for small practices like mine—a private practice with three partners—these programs will become a requirement under the Patient Protection and Affordable Care Act. This move from voluntary to mandatory compliance plans is especially evident for health care that enrolls patients and federally funded payer programs such as Medicare.

In order for health care providers to qualify for reimbursement, they must adhere to compliance standards. Just as smaller providers had to move from ICD-9 to ICD-10, health care providers will be expected to create and implement compliance plans.

The need for a compliance plan should encourage the development of internal practices that can control and oversee adherence to laws and other requirements. The Office of the Inspector General (OIG) encourages practices to create a culture for compliance. Doing so with your team, for both plan creation and implementation, is an important step. Your diligence in this regard will prove well worth the effort, both for your patients and for your team’s integrity.

The consequences of not implementing compliance standards include a variety of sanctions, ranging from financial penalties to exclusion from federal and state health programs. Very serious infractions can even lead to incarceration.

HOW TO PREPARE

To prepare an effective compliance plan, first, you must know what to do, and second, you must do it by making your compliance program effective in real time.

The OIG has outlined seven fundamental elements of an effective compliance program.1

No. 1. Implement written policies, procedures, and standards. The OIG, Health Insurance Portability and Accountability Act, and Occupational Safety and Health Administration have set forth compliance standards. You must write out these standards for your practice and address how your team will adhere to them.

No. 2. Designate a compliance officer and committee. Your compliance officer needs to be a person of high integrity who has the authority to influence your employees’ behavior. This person should report to the highest level of management in your organization to ensure that benchmarks for implementation are being met and that weak spots are being addressed.

No. 3. Conduct effective training and education. Compliance plans are a team effort. It is important for your team to know the applicable laws and how those laws affect their work. Your team should be trained on how to work in accordance with your standards, and they should be provided with an outlet where they can ask questions.

No. 4. Develop effective lines of communication. It is essential that your entire team be aware of the importance of meeting compliance standards. Be sure that everyone is aware of how to report suspicious practices and to whom to direct related questions.

No. 5. Conduct internal monitoring and auditing. Your team is responsible for upholding the standards before an outside company seeks an audit of your practice. Although the primary point of implementing a compliance plan is to protect patients, the internal audit is dual purposed. You want to do your best to protect patients, but you also need to make sure that the work you are doing always meets your compliance plan.

No. 6. Enforce standards through well-publicized disciplinary guidelines. Make your team aware of the importance of upholding compliance standards. If the standards are broken, your compliance offer should investigate the incident, communicate with the offending employee, and confer the penalty designated by your office. These disciplinary actions must be established and well known to everyone on the team.

No. 7. Respond promptly to detected offenses, and undertake corrective action. Corrective action can be internal, but should you detect a more significant infraction, it is imperative that the offense be reported to the federal government. Immediate disclosure of infractions can help prevent sanctions and a ruined reputation.

CONCLUSION

Ultimately, you and your team are responsible for the careful implementation of a compliance plan. I recommend you get a head start on what will soon be a requirement for your practice. n

1. Office of Inspector General. Health care compliance program tip. oig.hhs.gov/compliance/provider-compliance training/files/Compliance101tips508.pdf. Accessed January 4, 2016.

Matt Jensen, MBA
• CEO of Vance Thompson Vision in Sioux Falls, South Dakota
• certified Experience Economy expert and regular lecturer on customers’ experiences in health care
• (605) 371-7120; matt.jensen@vancethompsonvision.com