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Compliance Is Not Complicated

To be sure your providers and employees are following all rules and regulations to keep your medical practice compliant, you should create a compliance program. The Office of Inspector General lists seven core components for an effective compliance program.

  1. Implement standards through written policies and procedures

Providers and employees need written policies or procedures to know what is expected, what rules are out there, and how these are to be followed.
Provide your clinic with Standards for Conduct. Specify in writing what is expected from employees. State that they are to act in a truthful manner in both communication and conduct, and that your organization adheres to ethical standards such that patients are to be treated with respect, dignity, and fairness. Stipulate that employees are held in the highest standards of professional responsibility in compliance with regulations and requirements for federal and state laws.

  1. Designate a compliance officer and committee

Employees will need to know who to turn to with questions or concerns. That person is a designated Compliance Officer, who will be a direct link to a Board, CEO, or Upper Management. If possible, you also should select a committee to work with the Compliance Officer. The committee helps in the decision process, collectively creating written policies and procedures, and provides the tools for education and training. The officer and committee are also responsible to provide a process in which an employee may report any concerns regarding fraud, waste, or abuse.

  1. Develop effective lines of communication

Provide a tool for physicians and staff to voice their concerns regarding fraudulent behavior, and state consequences for noncompliant behavior. Make it easy. Include in your compliance training where an incident report is accessible to all clinic employees. Create a process to send the incident report anonymously or electronically to your Compliance Officer, or to a member on the compliance committee.

  1. Conduct a system for monitoring, auditing, and identifying risk

Use your findings to develop policies, procedures, and education and training, and as a basis for future audits. Keep current with all rules and regulations of the payers for which your office or clinic works, and follow the guidelines provided by the Office of Inspector General.

  1. Create a process for reporting issues and prompt responses

Create an easy process not only for reporting, but to do so anonymously. Encourage all employees by giving them a voice. Provide a slot box or create an incident form where employees may send the form electronically with a “no name” email address to remain anonymous, if they so choose.

  1. Conduct effective training and education

Create benchmarks to determine if the education and or training were effective. Follow through with corrective action needed to follow the specific rules and regulations set forth by the payers for which claims are filed for payment of services.

  1. Enforce disciplinary standards through publicized guidelines

Provide written guidelines for discipline. Let the employees know what actions may be imposed for noncompliant behavior or actions. Be sure to outline the consequences of noncompliance, such as retraining, verbal or written reprimand, warnings, probation, and, lastly, termination of employment.

Certified Professional Compliance Officer - CPCO

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Katherine Rhodes, BSE, CPC, CMCO, AAPC Fellow is a Compliance Manager for a multispecialty organization with over 100 providers. She has over 21 years’ experience in the healthcare field, an AAPC member since 2003 serving as past President, President Elect and current Education Officer and an instructor for over 10 years teaching Medical Coding, Terminology and Billing.

No Responses to “Compliance Is Not Complicated”

  1. Tami says:

    Katharine, thank you for a clear and concise article. Just starting in this field of study and your writing contributed to my understanding of the compliance topic. Thanks again.

  2. Regina says:

    I work for an interventional cardiologist,. When we have a patient that has insurance that is not par with the physician, I get told to bill the insurance for the patient, I do it for the denial and to cover myself, but then I was told by the office manager to decrease the charge amount to self pay rates. I believe this is illegal and have told both the office manager and the physician this and I am told just to do this. When this is told to me I document in the chart what and whom said this to me. Am I correct believing this is incorrect billing practice? I have tried to show them compliance documentation to no avail. Please help