2. I am a practitioner
I don’t like more regulation
I want to make and keep as
much revenue as I can
I want to be efficient
I want to provide quality care
I want to sleep at night
We want the same things
3. Required by law if you accept federal funds
Will be enforced in ~2014
Proactive vs. Reactive
OIG provides guidelines and help
5. CMS announced in June that during the first
calendar quarter of 2011, it found and recovered
$162 million in overpayments—more than
doubling the $75.8 million recovered in the last
calendar quarter of 2010.
6. $10-50,000 per violation
Repayment of over payments
Jail time with fraud
Sanctions
Exclusion
Corporate integrity agreements
7. Who evaluates the OIG exclusion list?
Which EM guidelines does your practice use?
What was the error rate of your last chart
audit? How did you fix the problems?
Do you have a Code of Conduct?
Do you have a compliance
hotline/officer/log?
Does your billing service have a
compliance program?
8. Provides a protective shield
Reduces risk of whistleblowers
Increases revenue
Improves documentation and coding quality
Providing medically necessary, quality care
9. 1. Written policies and procedures
2. Compliance professionals
3. Effective training
4. Effective communication
5. Internal monitoring
6. Enforcement of standards
7. Prompt response
10. Policies and procedures are up to-date and
user-friendly
Standards of conduct
Code of conduct
Retention of Records and Information
Systems
Compliance as an Element of
Performance Plan
11. Site Name is committed to providing quality,
comprehensive health care to the patients of
our Community. Our services will be
provided in a professional manner within a
safe and orderly environment. All personnel
will be expected to maintain high moral and
ethical standards and abide by the State and
Federal regulations as they pertain to the
delivery of health care. All personnel will
adhere to the Compliance Program of Site
Name.
12. Compliance Officer or Compliance Committee
Oversee the implementation
Maintenance
Effectiveness
Company watch-dog
13. JOB DESCRIPTION:
Effective Date:
Approved By:
Policy Number:
Page(s) 1 of 2
Title:
Job Title: Compliance Officer
Department: Administration
Reports to: Board of Directors, President, Physician Services Organization
Job Summary:
The Compliance Officer is responsible for the administration, evaluation and continued development of the
Compliance Program to ensure adherence to applicable state and federal healthcare laws, statutes and
regulations.
Job Responsibilities:
Design, develop, implement and monitor a comprehensive Compliance Program in accordance with the Code of
Conduct and Compliance Program Elements.
Develop and implement policies and procedures necessary to adhere to applicable state and federal healthcare
laws, statutes and regulations.
Submit annual budget for Compliance Program activities.
Provide monthly report of Compliance Program activities to the Board of Directors.
Coordinate, conduct and facilitate audit functions to identify inappropriate conduct or behavior. Provide
subsequent education and materials to implement corrective actions as necessary.
Coordinate, conduct and facilitate continued educational programs for providers and personnel that contain
focused emphasis on the seven elements of the Compliance Program.
Continually revise policies and procedures to reflect current changes in state and federal healthcare laws,
statutes and regulations.
14. Formal Training Programs
Informal On-going Compliance Training
Staff
Physicians
Billing department
15. PURPOSE:
The purpose of compliance training is to provide continual information concerning the Compliance Program policies and procedures and
to ensure personnel have information necessary to perform their job responsibilities in accordance with all applicable federal and state
laws, statues, and regulations.
POLICY:
Compliance education will be conducted at least annually or more frequently if necessary. Education will include the Code of Conduct,
the elements of the Compliance Program and Compliance Program policies and procedures. All personnel are required to attend
compliance educational programs. Education will be of a frequency to ensure personnel are aware of changes or additions in the laws,
statutes and regulations concerning the delivery of healthcare in a clinical environment. All new personnel will receive compliance
training within sixty days of employment start date.
PROCEDURE:
It is the responsibility of the Compliance Officer to:
Develop the content of the educational material used for compliance training.
Schedule and direct compliance training activities.
Develop and implement modified or new compliance policies and procedures if necessary.
Monitor results of educational activities to ensure personnel compliance with all state and federal laws, statutes and regulations. Provide
additional education if necessary.
Provide new employee compliance education within sixty days of employment start date.
Provide all employees with at least annual compliance education or more frequently if necessary.
Provide information regarding the consequences of non-compliant behavior, conduct or activities to all employees on a quarterly basis.
Provide information regarding the consequences of not reporting suspected non-compliant behavior, conduct or activities to all
employees on a quarterly basis.
Evaluate and make recommendations to the Compliance Committee regarding educational opportunities available to personnel that may
be provided by other entities.
Provide the Compliance Committee with a quarterly report of compliance training activities.
16. Hotline or Other System for Reporting
Suspected Noncompliance
Routine Communication and Access to the
Compliance Officer
17. PURPOSE:
A Communication Policy will provide a format for providers, personnel and patients to anonymously present complaints regarding
alleged non-compliant behavior or conduct allowing prompt investigation and immediate remedy.
POLICY:
The Compliance Officer will maintain:
An ‘open door’ policy for all providers, personnel and patients to discuss compliance related issues.
A Compliance Bulletin Board strategically located within the practice site.
A telephone hotline for anonymous reporting of alleged fraudulent or erroneous conduct.
PROCEDURE:
A notice is posted on the Compliance Bulletin Board reminding patients, providers and personnel that they can discuss compliance
related issues with the Compliance Officer at all times.
Compliance related information with subject matter relevant to the delivery of health care will be posted to the Compliance Bulletin
Board. The Bulletin Board is placed in a strategic place allowing continual access by patients, providers and personnel. Materials
are reviewed on a monthly basis to ensure accuracy of information posted.
A separate telephone line has been established for reporting of alleged non-compliant behavior or conduct. The red telephone is
located in the office of the Compliance Officer, in a locked cabinet. An answering machine is attached to the line for twenty-four
hour contacts. The volume on the answering machine will remain in the ‘off’ position so callers leaving a message can not be
overheard. Hotline information will be posted to the Compliance Bulletin Board encouraging communication between providers,
patients and practice personnel.
The Compliance Officer will monitor the telephone on a daily basis, documenting all calls. Responsive actions will be initiated
within twenty-four hours of receipt of alleged complaint. The Compliance Officer will maintain confidential files on all hotline
activity documenting actions taken. An activity report will be generated on a monthly basis and provided to the Board of
Directors. All calls will be assigned a number, to maintain informant confidentiality.
The Compliance Officer and the Practice Manager will have a key to the telephone cabinet. During an absence of the Compliance
Officer the Practice Manager will monitor the hotline.
19. Consistent Enforcement of Disciplinary
Policies
Employment of, and Contracting with,
Ineligible Persons
20. PURPOSE:
Establishment of disciplinary actions for violations of the Compliance Program encourages strict adherence of state or federal laws, statutes, or
regulations.
POLICY:
Inappropriate behavior, conduct or activities will result in penalties or disciplinary actions.
Failure to report inappropriate behavior, conduct or activities will result in penalties or disciplinary actions.
Penalties will be fair and consistent. Mitigating circumstances will be taken into consideration.
All providers, practice personnel, vendors, contractors or other individuals or entities providing health related services will be informed of the
consequences of violating the Compliance Program.
PROCEDURE:
Each case will be evaluated to determine the severity of the violation allowing for any unusual or mitigating circumstance.
All disciplinary actions will be under the supervision of the Compliance Officer.
Cases will be referred to the appropriate authorities for criminal prosecution if recommended by legal counsel.
Reckless or intentional disregard for state or federal laws, statutes or regulations that apply to the delivery of healthcare will result in employment
termination.
Offense:
First Offense, minor or mitigating circumstance Documented oral warning
Second Offense, minor or mitigating circumstance Additional Education; retraining
Third Offense, minor or mitigating circumstance Written Reprimand
Fourth Offense, minor or mitigating circumstance Termination
First Offense, serious or severe Probation Period or termination
Second Offense, serious or severe Demotion or termination
Third Offense, serious or severe Termination
Enforcement actions will be equally administered to all providers, practice personnel, vendors, contractors or other persons or entities providing services
to the practice site.
21. Responding to Offenses and Developing
Corrective Action
Reporting to the Government
23. Referral from a physician
to another health service
Is there a financial
relationship
Is there an exception
(safe harbor)
24. Prohibits asking for or receiving anything of
value to induce or reward referrals of Federal
health care program business
25. Prohibits the submission of false or
fraudulent claims to the Government
On the back of the claim form
Documenting medical necessity
Lack of documentation
Incorrect billing/coding
27. A message of
quality and caring
to stakeholders
To improve revenue
To build a culture
of quality, safety and collaboration
As a tool of fiduciary responsibility
In marketing messages
When renegotiating insurance
contracts
28. Mark A. Testa, DC, MHA, MCS-P
Doctesta@hotmail.com
303.885.9630
It takes less time to do things right
than to explain why you did it wrong.
Henry Wadsworth Longfellow
