10 Compliance Tips From the Office of the Inspector General

I recently had the opportunity to attend a provider compliance training conference hosted by the Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint effort by the Centers for Medicare and Medicaid Services, the Department of Justice and the Office of the Inspector General for Health and Human Services. In the notes that were provided, they list 10 practical tips for creating a culture of compliance:

1. "Make compliance plans a priority now." Mandatory office compliance programs are coming. It is expected that the final rules will be in place by the end of the year. You should be putting your compliance program in place now so that it will be operational by the time it is required.
   


2. "Designate (and empower!) an individual or team responsible for compliance." CMS and the OIG believe that you should have a designated staff member to conduct your office compliance program. If you cannot afford a trained staff person, they recommend that you outsource your compliance activities to a consultant. For the average chiropractic office, the best option is usually to have a designated staff member working with a consultant trained and certified in compliance.
   


3. "Know risk areas." The primary risk areas in any office are documentation, coding, billing, marketing and financial arrangements. Each of these areas can put you at risk of fines, penalties and possibly jail. An effective office compliance program will have procedures to identify and mitigate risks.
   



4. 

   "Manage your financial relationships." Financial relationships are where doctors most often run afoul of the Stark and anti-kickback laws. The wrong financial arrangement can put you at risk of fines, penalties and possibly jail.
   


5. "Educate your employees." If you don't educate your employees in how to perform office activities and procedures in compliance with all applicable laws, rules and regulations, they could easily put you at risk without knowing it. Regular training keeps the entire staff informed of changes in policies and procedures.
   


6. "Carry a message of compliance from top to bottom." Compliance starts with the doctor. It is your practice and you need to lead the way. I know that learning new procedures is not easy and that proper documentation takes time, but you are the one at risk if problems are found. Commit yourself and your team to compliance, delegate the job to a staff member and support their actions. You need to be in compliance no matter how uncomfortable it might be to get there.
   


7. "Conduct audits." One of the elements of an effective office compliance program is self-monitoring and auditing. The problem is that it is very hard to objectively judge your own notes. This is where a consultant is very helpful. A properly trained and certified consultant can review a sampling of your notes and tell you where your deficiencies are and how to fix them.
   


8. "Just because your competitor is doing something doesn't mean that you can or should. Call 1-800-HHS-TIPS to report suspect practices." Now don't go around saying that Doc Short is telling you to turn in the guy down the street. I'm not, but the OIG is, so I will address the rest of this to the guy down the street. If you are doing something that you should not be doing (such as waiving deductibles and co-payments, giving free examinations or offering other free services to Medicare beneficiaries), you are making yourself a target. Most doctors who are under investigation are there because someone turned them in. Disgruntled employees, former employees and competitors are most likely to turn someone in. Don't make yourself a target by doing illegal practices and procedures.
   


9. "Open lines of communication." Communication is key to an effective office compliance program. Communication of policies and procedures from the decision-maker(s) out to everyone and communication of problems to the decision-maker(s) are both equally important. Establishing and maintaining open lines of communication will go a long way toward helping an office get and stay compliant.
   


10. "When in doubt, ask for help." Staying current on the laws, rules and regulations is a full-time job. For example, in 2009, Health and Human Services changed the way it conducts reviews. The result of this change is that the national error rate for 2009 started at 7.8 percent and ended at 12.4 percent. This means that anyone who passed a review in early 2009 probably will not pass now. My point is that it is very easy to miss a detail in regard to compliance. Help is available and you should take advantage of it.

As you can see from these 10 tips, the CMS and the OIG are very serious about combating fraud waste and abuse in the Medicare program. They recognize that the only way Medicare can continue to serve its intended beneficiaries is to not pay for any medically unnecessary services. They see the office compliance program as essential to accomplishing that goal. They do not expect it to be just another government-mandated notebook sitting on your shelf.

The office compliance program is a must for the successful chiropractic practice. When utilized properly, it can save you more money than it costs. Having your policies and procedures written out and your staff regularly trained will increase your office efficiency. Regularly monitoring your claims for denials and responding rapidly to any identified problems will save you both time and money.

The greatest benefit of an effective office compliance program is that virtually every federal agency considers it to be a mitigating circumstance to the imposition of fines and penalties. The only catch is that the program must be in existence before you are investigated. If you have received a comparative billing report, I seriously advise you to look into an office compliance program soon.

Mandatory office compliance programs will be here by the end of the year. Both CMS and the OIG expect you to put one in place and will be looking for them. The sooner you get one in place, the sooner you can start realizing the benefits and avoid the consequences of not having one.