Updated on: June 22, 2012

New Levels of Enforcement Mean Significant Risk for Providers

By
Original story posted on: May 5, 2010

bbissey120dsIf you were one of the more than 2,000 people in attendance at the Health Care Compliance Association’s annual institute in Dallas this April, you probably were impressed, as I was, with the increased focus and energy that our government and enforcement colleagues brought to the meeting. I was left with the distinct impression that compliance programs need to be in place and functioning within the organizational structure and culture of all healthcare providers. Furthermore, if providers believe that the roles of their compliance programs should be diminished, or that they really aren’t that important to their organizations, they are putting themselves at significant risk due to the new levels of enforcement.

 

If you are one of those many providers who have embraced compliance and adopted a forward-thinking, independent, transparent and robust compliance program, your efforts are to be applauded. If, on the other hand, your organization has not embraced compliance as a culture, buried the program in an isolated area of the hospital, reduced the program’s budget, failed to assemble a learned board, or downsized your efforts –  it might be a good time to revisit of what elements a solid compliance program consists.

 

As a refresher, every healthcare provider always must be concerned that if you have a longstanding billing/documentation practice that is inconsistent with accepted and applicable billing/documentation standards (ex: medical necessity), one potentially could argue that you have an unacceptable “pattern or practice” of billings. This could subject you to further reviews (and longer time periods), with the potential for discussions of larger paybacks and possibilities of fines and/or penalties, plus all of the expense and negative exposure that entails. In today’s regulatory climate, it is quite possible that civil and criminal investigations could ensue if a provider is shown to have behaved in a manner that reveals intent to defraud the government.

 

What I believe is similar between the RAC initiative of today and previous investigations/areas of focus is that all providers have the opportunity to utilize the Office of Inspector General’s Model Hospital Program Compliance (first published in 1998 with a supplemental document published in 2005) as a proactive resource/planning tool to prepare for the RAC initiative. Obviously, providers in some parts of the country already have experienced the pain of RAC reviews. However, whether you have “sat across the table from the RAC,” appealed an identified overpayment(s), or simply have  not done anything to prepare, a refresher on the elements of the OIG Model Compliance Program Guidance for Hospitals (“CPG”) is a must-read at this time.

 

The introduction to the basic Compliance Plan Elements of the 1998 hospital CPG below is a summary of the structure and processes that make up the recommended seven elements of a compliance program. The seven basic elements of a compliance program are:

 

    1. Designation of a compliance officer and compliance committee;
    2. Development of compliance policies and procedures, including standards of conduct;
    3. Development of open lines of communication;
    4. Appropriate training and education;
    5. Internal monitoring and auditing;
    6. Response to detected deficiencies;
    7. Enforcement of disciplinary actions.

 

It is clear that one of the most important elements to having a successful compliance program is the direct commitment and involvement of your board and senior management. Hospitals that have an organizational culture that values compliance are more likely to have effective compliance programs, and thus are better able to prevent, detect and correct problems. At this juncture, all of these individuals (board and senior management) should be informed fully about the government’s RAC and other initiatives and their applicability to your institution. Furthermore, they should be made aware of the increased attention being placed on fraud and abuse issues. If for some reason your board and/or senior management is not aware of the importance of your organization’s compliance program in 2010 and beyond, I would recommend holding an educational session to discuss all that is happening in the industry. You may want to consider having an external expert make the presentation.

 

Your compliance program is a very important element of the success of your organization’s future. Please take all appropriate steps to ensure that leadership is aware and educated!

 

About the Author

 

Bret S. Bissey, MBA, FACHE, CHC, is a nationally recognized expert in healthcare compliance. He is the author of the Compliance Officer's Handbook, published in 2006, and has presented at more than 40 regional and national industry conferences/meetings on numerous compliance topics. He has more than 25 years of diversified healthcare management, operations and compliance experience.

 

Contact the Author:

 

bbissey@ima-consulting.com

Bret Bissey, MBA, FACHE, CHC

A veteran in healthcare compliance (since 1997), Bret Bissey has served as senior vice president and chief ethics compliance officer at UMDNJ in Northern New Jersey. The author of the Compliance Officer’s Handbook, he has been a thought leader and popular speaker at industry conferences and meetings for many years. Bissey has more than 30 years of diversified healthcare management, operations, consulting, and compliance experience.

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