Today’s regulatory environment makes practicing medicine a complicated business for those who are unprepared. There are a number of federal statutes that include healthcare compliance provisions.
Particularly since fraud and abuse prevention has been a focal point for the Office of the Inspector General (OIG), Department of Justice (DOJ) and the Department of Health and Human Services (HHS), healthcare professionals must guard against getting caught in the crosshairs.
An increase in civil, criminal and administrative enforcement actions raises the precaution level. One way to ensure your practice is not named in one or all of these legal actions is to create a compliance program.
It has become a standard practice, whether mandatory or voluntary in some states. Recent changes in the law have made compliance programs mandatory. Therefore, implementing a program in your healthcare practice can help to protect you from accusations of abuse or fraud.
Why Your Practice Needs a Healthcare Compliance Program
Many reasons exist to support why your practice should create a compliance program. OIG has announced that healthcare providers who operate without this type of program could face serious penalties as a result of enforcement actions.
Numerous providers are subject to OIG Compliance Guidelines:
• Nursing homes
• Small group practices
• Individual healthcare practices
• Hospice facilities
• Third-party billing companies
• Home health agencies
• Durable medical equipment vendors
• Pharmaceutical manufacturers
• Ambulatory services
Federal sentencing guidelines are another factor in protecting your practice against claims of fraud or abuse. There are provisions for entities with compliance programs that could reduce criminal penalties if there is a healthcare fraud conviction.
Additionally, the Affordable Care Act requires that providers who participate in Medicare, Medicaid and other federally funded programs must have a compliance program in place.
Requirements of a Healthcare Compliance Program
To meet regulatory requirements, your healthcare compliance program must contain the following provisions:
• Training and education for healthcare providers and employees
• Internal monitoring and auditing to catch lapses ASAP
• Corrective action if/when an offense occurs
• Distribution of practice guidelines
• Open communication
• A designated compliance officer to oversee the program
While there are specific standards, an effective compliance program take into account individual practices. Fraud prevention is the ultimate goal. However, the program should be structured in a way that detects and corrects a mishap.
The program should address key activities that can leave your practice exposed. These activities include:
• Billing and coding
• Medical records
A compliance program does not guarantee that your practice will never be investigated. However, it could be extremely helpful in reducing the fallout that an investigation could have on your medical practice.
Work with a Healthcare Compliance Program Lawyer
The healthcare industry faces increased regulation and enforcement. A compliance program becomes an essential tool to protect your practice from claims of fraud and abuse. Findings of guilt can lead to high fines, exclusion from government healthcare programs, loss of your professional license and possibly even a prison sentence.
Make sure that you have an effective compliance program that addresses the specifics of your practice in accordance with the law. Consult with an experienced healthcare lawyer who can guide you through setting up and implementing the right program.