Compliance programs are an effort by the government to maintain integrity in the healthcare system. These programs target activities causing improper payment to determine their root cause: Was it a mistake or error, was it inefficiency or waste of resources, is the provider bending the rules or abusing the system, or was it intentional deception or fraud? There are also laws dictating the compliance culture within practices and institutions; for example, red-flag rules, antikickback statute, and stark law, to name a few.
The Office of Inspector General (OIG) is dedicated to combating fraud, waste, and abuse, and to improving the efficiency of federal programs funded by the government, including Medicare and Medicaid. The OIG has several audits in place regulating medical necessity, documentation, and medical identity theft to reduce fraudulent billing. Your practice may benefit from implementing a compliance program to prepare it for healthcare reform initiatives.
Compliance programs vary depending on the size of the practice, whether it’s private or hospital owned, and other variables. Implementing a plan now that promotes transparency, quality, and accountability will facilitate the groundwork for healthcare reform initiatives. An effective compliance program starts with:
- Formal written guidelines, policies, protocols, and codes of conduct. Supporting documentation is required to confirm policies are enforced fairly and training provided yearly;
- A dedicated compliance officer or committee, depending on the size of your practice;
- Proper training and education, especially on the stiff penalties associated with improper documentation and billing/coding practices; and
- Internal controls and a prominently posted list of the people responsible for each aspect of the program.
Types of Audits and Auditors
The most common audits and auditors are:
- Recovery Audit Contractors (RACs): These identify and recover improper Medicare payments paid to healthcare providers under fee-for-service Medicare plans.
- Zone Program Integrity Contractors (ZPICs): These identify and recover pre- or postpayments of claims lacking medical necessity. If a ZPIC comes knocking on your door, there are potential Medicare fraud implications.
- Medicaid Integrity Programs (MIPs): These review Medicaid provider activities, audit claims, identify overpayments, and educate providers and others on Medicaid program integrity issues.
Without continuous education and monitoring, the program will not sustain itself. Remember to:
- Set and measure goals and effectiveness;
- Effectively communicate expectations and disciplinary courses of actions;
- Perform internal audits and continuous monitoring; and
- Enforce policies and procedures accordingly and follow through with corrective actions.
The OIG and the Centers for Medicare and Medicaid Services (CMS) work together to conduct audits throughout the U.S. Physicians and/or their practices are grouped into geographical regions or jurisdictions and independent contractors are hired to oversee audits in that area, collect data, and report to both CMS and OIG. When compliance issues arise, documentation is vital. The rule of thumb is, “If it is not documented, it didn’t happen”; therefore, every visit must be documented and support medical necessity to validate your billing and coding practices.