Compliance Program Coverage and Why You Need One

complianceIn recent years, the government has stressed the importance of the implementation of compliance plans in healthcare organizations. According to Damaris L. Medina, healthcare attorney with Michelman & Robinson, LLP, based on the Affordable Care Act, if a healthcare provider is enrolled with Medicare, Medicaid, or the Children’s Health Insurance Program, a mandatory compliance program must be put into effect. However, for the rest of the industry, Medina says compliance programs are not mandatory, but are highly recommended as a form of security for a healthcare provider. Medina and other professionals heavily involved in the healthcare industry discuss the necessary areas a company should cover in a program and why you should have one in place at your UCC or ASC.

According to Medina, a compliance program’s main focus within a health care company is to ensure that policies and procedures are in place, that they are enforced, and that there is a way to respond to any compliance risks if, and when, they arise. Generally, the document is drafted by healthcare legal counsel, and this is the route Medina recommends. However, there are companies in the industry that can be assigned to assist in the creation process.

Medina says that once the program is in place, the UCC or ASC should elect a compliance officer or committee, whose job it will be to overlook the program and ensure proper implementation amongst employees.

“A compliance officer’s job is to create a culture of compliance within an organization. They are the ones in charge of making sure that the compliance program runs effectively and efficiently,” Medina says.

Anthony White, office manager at A Family’s Urgent Care, located in Merced, CA, says that awareness of the compliance program among employees is most important in a clinic.

“We do quarterly trainings, we have an internet program that walks them through internet safety and they do that twice a year. We have paperwork that they go through probably every three to four months. It does get redundant, but as we do it, it jogs their memory. Situations don’t come up all of the time, but it prevents them from coming up too regularly,” White says.

White says his clinic got serious about compliance programs and developed one about three years ago when Meaningful Use was in full swing, which was Medicare’s mandate for compliance. White says that even though the Medicare guidelines were a more specific, mapped out compliance program, most practices have always been concerned with HIPPA compliance.


What should you cover in your Compliance Program for 2015?

Medina says that one of the reasons compliance programs exist is to ensure that providers are documenting well, and that the proper coding is assigned, and ultimately billed, for the services provided during every patient encounter.

“The government has assigned funds for the purpose of investigating and addressing healthcare fraud. Private payers have followed suit, by scrutinizing providers’ billing for appropriateness and medical necessity. They are looking at what doctors are coding and billing and making sure that their actions are appropriate,” Medina says.

Specifically, in settings such as an urgent care center, Medina says that the government is looking at certain things. One issue she discusses is upcoding within an E&M service code.  Medina says that the examination of this issue involves questioning whether or not the appropriate level of coding was provided based on the actual services provided.

“That’s one of the things that the government and private payers look at, that compliance programs address.  Another is the use of lab testing and radiology studies. Both private and government payers scrutinize providers for the medical necessity of ordering lab tests and radiology studies.  They want to make sure that providers are not charging for lab tests that aren’t necessary,” Medina says.

Billing and coding are not the only issues examined while preparing a compliance program for a center. Medina says that other concerns involve contracts entered into with other providers, including referral agreements or other contracts that may run afoul of the Stark and Anti-Kickback laws.

Medina goes on to explain some examples of the policies that can be put in place to prevent potential future problems for a center.

“One of the policies that we recommend is to have an internal system for pre and post billing review of claims.  We also recommend internal policies and training that address provider documentation.   In addition, we recommend a system of annual external coding audits on a yearly basis.  We work with providers to send a representative sample of claims to an external auditor we trust.  We then work with the auditor to make sure that there are no issues with the documentation, coding, or the billing process.   They are going to take all of their claims and send them to an external audit once a year. The coder will look at those claims to make sure there are no issues with them. If any issues do pop up, then we will recommend changes to internal procedures so that more errors don’t occur.  We believe this is a good practice, even if the provider has a billing company,” Medina says.

White adds that second and third party contracts are also an issue to look out for when implementing a compliance program at your center. He says that ensuring paperwork signed and in place consistently can be a challenge but must be a first thought in order to remain compliant.  White says it is easy to forget that another party’s access to even one patient’s name requires having a contract in place.

Medina stresses that issues regarding HIPAA are presently very much on the government’s radar.  She says a compliance program will have policies and procedures in place that direct how health information needs to be maintained and for how long, how it needs to be destroyed, who can have access to it, etc.

White adds that in the latest age of advances in health care, technology has now become an aspect of remaining compliant.

“As we turn the corners and become more and more electronic and the computer is taking more and more data from us; as we turn the corner for electronic records and electronic information, staying ahead of the curve as that technology changes, is probably what I think is the most important,” White says.

He adds that between cell phone, tablet and email usage, it becomes very easy to use a tool that is non-compliant.  He says a tip to remaining compliant in the technology area is to keep staff in place, and keep staff remembering that they cannot go into those gray areas and must stay in secured networks.

“People will automatically fall into what is comfortable. A lot of our staff are twenty-somethings, so texting, and those shortcuts, that is their comfort level. We are reigning into ‘no you’ve got to stay compliant and it has to be secure data,’” White says.

Medina explains that regarding emails, a compliance program may also have written document retention policies. This will say when emails get archived, when they should get discarded, when they don’t get discarded, and who has access to them.


Why Does Your Center Need a Compliance Program?

Frank Sheeder partner at law firm DLA Piper LLC, Chair, Health Care Enforcement and Compliance Practice says compliance programs are aimed at preventing, identifying and mitigating risks.

“It makes good business sense to have a robust compliance program, especially in today’s active enforcement environment,” Sheeder says.

Sheeder says that government and other third parties will treat a center more harshly if there is not a compliance program in place.  Sheeder adds that investigations and enforcement actions, even if not well-founded, can create substantial legal, financial and reputational risks.

“It is better to find and to resolve a potential issue proactively than to be in a defensive, reactive posture.  A compliance program helps with this,” Sheeder says.

White discusses an example of when their compliance program helped them to avoid fees when a business associate filed a complaint against his office.

“It didn’t go anywhere, we didn’t end up with a fine, but it was about 15 hours of work on my behalf of correspondence and proofing that was unnecessary. No, it didn’t cost us the huge fine, but when you look at the man hours that it takes to address the issue with the government, it does cost the practice,” White says.

Medina says that no matter the size of your center, having an effective compliance program in place is the best way to minimize risk in regards to the major risk areas in compliance.

“It’s something that I think small groups don’t think about, but it’s something that for a small group is fairly easy to implement. It’s a better safe than sorry kind of thing,” she says. “In my view, every single healthcare organization should have one based on the audit activity we have seen in the past five years.  The scrutiny providers are under spans from the one provider office to the large democratic organizations.  It doesn’t matter how small you are, you could be at risk. Therefore you need to have a compliance program in place, even if it’s a lot simpler than that of a larger organization.”

Sheeder explains that there are many resources available to help a center to design an effective compliance program.  As an example, he refers colleagues to the Health Care Compliance Association, which he says has a vast library of compliance materials that are available to its members.

“While lawyers and consultants can often guide the process, the best compliance programs for smaller entities are those that are developed in-house and designed to accommodate a center’s risks, resources, and culture,” he says.


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