Q . What is the Office of Inspector General compliance program for physician practices, and are all physician practices required to have a formal compliance program?

A. The OIG previously developed a voluntary compliance program focused on several other areas and aspects of the health-care industry. The OIG believes that development of a compliance program for individual and small-group physician practices will assist providers in preventing submissions of erroneous claims or engaging in unlawful conduct involving federal health-care programs.

Although a deadline for mandatory implementation has yet to be established, the Patient Protection and Affordable Care Act states, in Section 6401, that “...a provider of medical or other items or services or supplier within a particular industry, sector or category shall, as a condition of enrollment in the program under this Title ... establish a compliance program.” This means that physician ability to enroll in federally funded programs, e.g., Medicare and Medicaid, will rely on the practice’s having a formal compliance program.  

Q . Who will establish the mandatory guidelines and set the implementation date?

A. The Secretary of Health and Human Services, with assistance from the OIG, will establish the core elements of a program and the required implementation date. In a recent Center for Medicare & Medicaid Services webinar discussing compliance programs, listeners were encouraged to consider developing a program, even though no official deadline has been established.

Q . What is involved in developing a compliance program?

A. The program is actually a two-step process, and there is no one-size-fits-all plan. The first step is developing a written plan. Plan templates to get practices started are available from a variety of sources; these are customized to create a unique plan for the practice. Depending on the size and structure of the practice, legal counsel and/or outside consultants may be required to assist in analyzing contracts, performing a chart review and conducting necessary training. The second step is putting the program in motion by taking the written document and turning it into an activity. The activities are not one-time occurrences; therefore, the practice needs to commit to the program for the long term.  

Q . Do guidelines exist to assist with developing a program?

A. In the fall of 2000, the OIG published Compliance Program Guidance for Individual and Small Group Physician Practices. Many speculate that this guidance will be utilized when formulating the core elements as directed by the ACA. The October 2000 document can be found on the OIG website at: http://oig.hhs.gov/authorities/docs/physician.pdf.

Q . What are the core elements in the OIG guidance document?

A. There are seven core elements described in the OIG plan. They are:

1. conducting internal monitoring and auditing;

2. implementing compliance and practice standards;

3. designating a compliance officer or contact;

4. conducting appropriate training and education;

5. responding appropriately to detected offenses and developing corrective action;

6. developing open lines of communication; and

7. enforcing disciplinary standards through well-publicized guidelines.

Q. What is involved in auditing, and how extensive does the audit need to be?

A. Auditing involves a review of practice standards and procedures associated with patient care, as well as submission of claims for payment.
An audit of patient medical records and claims will assess whether the claims are accurately coded and whether the documentation is complete, and ensure that services provided are reasonable and necessary.  

The OIG guidance recommends a random sample of five to 10 charts per physician with a focus on federally funded programs. A comprehensive baseline audit is recommended as a starting point, assessing a small sample of everything. This is typically about 1 percent of all claims.

Q. Who should do these internal audits?

A. Audits can be performed by an independent party (e.g., attorney, consultant or accountant) or by practice staff. Internal auditors may include physicians, billing staff, medical assistants, a compliance officer or a committee of individuals.  

Q. What is the role and responsibility of a compliance officer?

A. The compliance officer should be someone of moderate authority, because while the role(s) and responsibilities may vary depending on the size of the practice, in general, they include:

• overseeing the program;

• establishing methods to improve quality and efficiency;

• revising the plan as needed;

• developing, coordinating and participating in training programs;

• checking the OIG’s list of Parties Debarred from Federal Programs;

• investigating any allegations of unethical or improper conduct; and

• monitoring corrective action programs.

Q. How does the compliance officer check the OIG’s list of Parties Debarred from Federal Programs?

A. The OIG has made this quite simple: there is a link on its home page for the list. It can be found at: http://oig.hhs.gov/ and is a large button that says, “Exclusions Database.” Searches may be performed for a single name or a list of names. The OIG spokesperson participating in the recent CMS webinar indicated that not checking the exclusion database is a common compliance error practices make.

Q. Are there any benefits to having a voluntary compliance program while waiting for mandatory implementation?  

A. Yes; developing a program will reveal a practice’s strengths and weaknesses.  At the same time, benchmarks, goals and objectives will be developed for the practice.

There are also several benefits to having a compliance program, as cited in the Federal Register (volume 65; number 194; October 5, 2000).  They include:

• speeding and optimizing proper payment of claims;

• minimizing billing mistakes;

• reducing the chances that an audit will be conducted by CMS or the OIG;

• avoiding conflicts with the self-referral and anti-kickback statutes;

• demonstrating good faith effort to comply with laws and regulations; and

• indicating that staff have an affirmative, ethical duty to report billing errors or fraudulent conduct so it may be corrected.   REVIEW

Ms. McCune is vice pres­ident of the Cor­coran Con­sult­ing Group. Con­tact her at DMcCune@corcoranccg.com.