Compliance

In health care, compliance refers to efforts by providers, contractors, and suppliers to ensure that the company or group and their physicians and employees adhere to the laws and regulations governing the workplace and the health care field. Voluntary compliance programs are strongly encouraged by the government. A well-crafted compliance program demonstrates the company's commitment to the ethical and proper way to do business, communicates company values and procedures to employees, requires adherence to the laws and rules governing health care practices, discovers and addresses problems, and constantly monitors to ensure the efficacy of the program.

There are many reasons for a company to implement a compliance program. The chief reason is to ensure that the company's values and safeguards are known and observed throughout the company. An effective compliance program must include a commitment to inform and educate employees and to define the legal and ethical obligations of each individual within the company. Key to the success of any compliance program is a clear, accessible means of reporting problems or concerns. The reporting procedures should provide for anonymity, but if the communicator is known, there must be assurances that the communicator's privacy will be protected and that the person will not be subject to any form of retaliation. Follow-up is equally important. Also essential is a well-defined system for investigating and addressing problems once they are made known. A successful program must demonstrate its ongoing commitment to compliance by performing regular audits and evaluations to ensure that the numerous aspects of the program are working properly and being followed. The compliance program should also include policies and procedures for redressing problems discovered and, where appropriate, should include mechanisms for reporting errors and overpayments to the proper authorities.

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services is charged with oversight of protecting the integrity of federal health care payment programs. OIG has issued health care guidelines for establishing and overseeing a compliance program in several areas of the health care field. The program elements are similar for differing segments of the health care market, but for this discussion the focus will be on the “Guidance for Individual and Small Practice Physicians.”

[Page 97]This OIG guide gives a clear road map for any health care provider or practice seeking to institute a compliance plan. Compliance programs for physicians should be viewed as a form of “preventive medicine.” Physicians have a duty to ensure that claims submitted to Medicare, Medicaid, and other federal health care programs are true and accurate. An effective compliance program is the best mechanism to ensure that billing rules are followed and that problems are discovered and corrected.

The OIG guide for implementing a compliance plan identifies the following steps:

• 1.
  Audit and monitor.
• 2.
  Establish practice standards and procedures.
• 3.
  Designate compliance officer or contacts.
• 4.
  Conduct appropriate training and education.
• 5.
  Develop a plan to respond to detected offenses and conduct corrective action interviews.
• 6.
  Develop open lines of communication.
• 7.
  Develop disciplinary standards through well-publicized guidelines.

Compliance programs can be narrow or broad. A basic program for physicians would focus primarily on billing issues. A more comprehensive program would include billing compliance, employment, safety, privacy, and other fraud and abuse laws. A comprehensive program should be the long-term goal. This is especially important in the current health care environment given recent efforts by federal enforcement agencies and qui tam relators to claim that many kinds of health care violations create a false claim or statement when billing for Medicare or Medicaid reimbursement.

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