Compliance in the Physician Office setting

Margaret (Peggy) Scherrer, RN, BSN, MBA, CHC, CHPC Profee Coding Leave a Comment

Compliance in the Physician Office setting

Small physician practices may find themselves challenged when managing a practice that has to address billing issues with payors, the adoption of complex workflows, and staying aware of all rules and regulations (Adler, 2015). Developing a Compliance Program may feel like a large task, but a Compliance Program can be an important tool for physician practices of all sizes and does not have to be costly, resource or time intensive (OIG, 2000).

The Office of the Inspector General (OIG) acknowledges that physicians need to take care of their patients, and that quality patient care be their first priority; but they go on to state that the physician office can benefit from instituting a Compliance Program. In 2000, the OIG released Compliance Program guidance for individual and small group physician practices that provided information on the type of activities needed to build a voluntary Compliance Program within the smaller office setting (OIG, 2000).

This OIG guidance states these voluntary Compliance Program measures are primarily related to claims submitted to Federal healthcare programs, such as Medicare, Medicaid, Tri-Care, and the Veterans Administration (VA). The Medical Practice can determine the scope and breadth of their Compliance Program based on their needs and resources, and can include information regarding all payors and known existing compliance issues.

Compliance Program controls lay the groundwork for the provider to identify their own risks and implement corrective actions which can result in:

  • Improved documentation efforts
  • Improved speed of claims processing, a decrease in billing errors, and fewer denials
  • Reduced chances of payor audits
  • Improved staff awareness, cooperation, and input
  • Avoiding conflicts with self-referrals (Stark) and anti-kickback statutes
  • A demonstrated effort to employees, patients, community, payors, and all government entities that the medical practice is committed to following laws, rules and regulations, and statutes (OIG, 2000)

The OIG has identified these seven basic elements of voluntary Compliance Program for a physician office:

  • Conducting internal monitoring and auditing through the performance of periodic audits
  • Implementing compliance and practice standards through the development of written standards and procedures
  • Designating a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards
  • Conducting appropriate training and education on practice standards and procedures
  • Responding appropriately to detected violations through the investigation of allegations and identification of corrective actions
  • Developing open lines of communication
  • Enforcing disciplinary standards (OIG, 2000)

These individual tasks might seem overwhelming, but they can be broken down into more manageable pieces of work. The following are examples of how these elements can be achieved:

  • Review denied claims submitted in prior months to determine where there are opportunities for improvement and set a corrective action plan into place
  • Identifying and reviewing office processes that can be incorporated into a formal “Office Policies and Procedures”. Those standards which are important to include are:
    • Referral processes
    • Copay/cost share collection
    • Hiring processes
    • Receipt of gifts
    • Vendor relationships
  • Identifying a Compliance Officer or Compliance Manager
  • Identify training needs for new staff, and development into a formal new employee training program
  • Ensure that all staff receive annual training and updates
  • Development of a process whereby employees and others can report possible issues in a confidential manner without fear of retaliation
  • Ensure that staff are receiving needed information by including Compliance discussions into staff meeting agendas or utilizing an office Compliance bulletin board
  • As policies and procedures are developed, there should be some reference to disciplinary standards and what could happen to the employee if there is a failure to follow the stated policy

It is recognized that many physician offices may already have these standards and activities in place as business practices. Formalizing these activities into a Compliance Plan, which is appropriate for the size of the office, can assist the Medical Practice to improve office activities and improve the billing process.

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