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by David Denton
There is a natural tension between a provider’s efforts to maximize reimbursement for services and the limits imposed on those payments by federal and private third-party payers. Although attempts to legitimately optimize payments should not be discouraged, practitioners face traps for the unwary without a firm understanding of the complexities of documentation, coding, and billing. Adopting a reimbursement compliance program can assist providers in making the most of reimbursement opportunities while minimizing and preventing negligent, unethical, and fraudulent conduct.
The Office of Inspector General (OIG) at the U.S. Department of Health and Human Services has developed compliance guidelines for individual and small group physician practices to promote practice patterns that foster adherence to the statutory and regulatory requirements of federal health care programs and, by analogy, private insurance payers. Although developed for medical practices, the OIG acknowledges that the guidelines are flexible and may be appropriate for adaptation and use by small speech-language pathology (and presumably audiology) practices. For larger practices, OIG guidelines for hospitals may be a more appropriate model. The guidelines are voluntary and intended to be implemented to the extent possible by the circumstances and resources of the practice.
OIG guidelines list seven components of a basic voluntary compliance program:
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Establish auditing and monitoring activities. A practice’s standards and procedures are periodically reviewed for currency and accuracy and to identify where its current compliance program may put the practice at risk.
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Develop written practice standards and procedures to address all identified areas of risk. The practice should develop written procedures to reduce the chance of coding and billing errors, filing of erroneous claims, and to deal with those particular areas that have been identified during the audit that put the practice most at risk.
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Designate one or more individuals to provide compliance oversight. The designated compliance officer(s) can be responsible for developing a corrective strategy to cure areas of identified risk, and for overseeing the practice’s implementation of its comprehensive compliance program.
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Conduct appropriate education and training of employees. At a minimum, OIG recommends all professional and support staff with any involvement in coding and billing be trained in the practice’s compliance standards and procedures. Training should consist of, but not be limited to, coding requirements, information on developing and submitting claims, federal and private health care program requirements in order to submit accurate bills, and the sanctions for non-compliance.
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Respond to and cure compliance breaches. A practice’s commitment to compliance includes ongoing monitoring in order to detect and respond to evidence of misconduct. If it becomes apparent that the compliance program is failing to prevent a particular type of violation, the program may require modification or that staff training be enhanced.
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Develop open lines of communication to foster compliance and reporting of violations. Policies should be developed to encourage meaningful and open communication to the designated compliance officer of suspected erroneous or fraudulent conduct and protecting, as much as possible, the anonymity of the reporting party.
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Develop and publicize guidelines to inform staff of the consequences of non-compliance. Employees at all levels must be accountable for the practice’s compliance requirements and subject to disciplinary action for their intentional or reckless non-compliance.
OIG compliance guidelines are a welcome tool for busy practices in developing and implementing internal controls that promote adherence to federal and private health care plans’ requirements for reimbursement. Visit http://oig.hhs.gov/fraud/complianceguidance.html for detailed information about OIG compliance guidance programs.
David R. Denton, director of ethics, can be reached at ddenton@asha.org.
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