Medicare Compliance & Reimbursement

There’s more to the Affordable Care Act (ACA) than making health insurance accessible to most Americans. Are you up to speed on the various compliance requirements? A recent bulletin issued by the U.S. Department of Health and Human Services Office for Civil Rights (OCR) highlights one of these aspects — enforcement of “Section 1557” of the ACA.

“Section 1557 prohibits discrimination on the basis of race, color, national origin, sex (including gender identity), disability, or age in certain health programs and activities. Of particular note, Section 1557 is the first federal civil rights law to prohibit sex discrimination in covered health programs and activities,” the bulletin informs us.

To step up its enforcement, the OCR initiated investigations into two separate complaints and caused the facilities to revise their policies. In the first instance, the emergency department of the Touro Infirmary in New Orleans, Louisiana refused appropriate care and treatment to a male patient who had been subjected to domestic violence and worsened the situation by subjecting him to rude remarks. However, as a result of OCR action, “Touro revised its abuse protocol to provide gender-neutral procedures for reporting incidents involving domestic abuse. Touro also provided training to its emergency department staff on identifying and assessing victims of domestic abuse,” the bulletin states.

In the second instance, St. Bernard Medical Center in Jonesboro, Arkansas, has had to revise its billing practices which used to treat married patients in a discriminatory manner. The Center would automatically assign the husband the role of guarantor for his wife’s treatment but the wife never bore the financial responsibility in case of the husband’s illness. Now the Center has “to ensure equal treatment regardless of the sex of the patient,” according to the bulletin.

“OCR is also using its authority under health privacy laws to enhance civil rights protections in addressing sex discrimination issues that arise in covered health care programs or activities. For instance, OCR recently provided technical assistance to a health clinic on appropriate treatment of transgender individuals after concerns were raised in the process of a privacy-related complaint,” the bulletin tells us.

Resource: You can read the entire bulletin at www.hhs.gov/ocr/office/1557_bulletin.pdf. You can also read about OCR actions and policies at http://www.hhs.gov/ocr/office/index.html.

Code of Conduct Policy

However, a code of conduct embraces more than sex discrimination. Developing a code-of-conduct policy can be complicated or simple. You can involve legal counsel and spend thousands of dollars, or you can simply meet with the management of your practice and start compiling relevant items. It can’t be something you simply place on a shelf or post on a wall. It must be enacted with care and deliverance.

Without proper management buy-in, positive leadership, and continuous emphasis and training, a code-of-conduct policy is useless, if not risky. If you’re subjected to an audit, the policy can be used against you if problems are found. If the policy states that “employees shall not participate in any false billings,” but the audit discovers errors in filed claims, the policy could be used to prove that there was intentional wrongdoing or fraud by the individual filing the claims.

One of the first things an OIG investigator will ask to review is the practice’s compliance manual and code-of-conduct policy. You can be assured employees will be questioned on its contents and meaning. Emphasis has to be placed on employees’ understanding the importance of what they are asked to sign.

Watch Out for Stark Violations

It’s crucial that employees feel they can establish comfort levels of communication with management so they can openly report problems and violations without fear of retribution or harassment. The policy should define the responsibilities of the physicians and their participation in partnerships that may affect the practice. This is especially relevant if the partnership involves a physician’s family member, such as a physician’s spouse who owns a durable medical equipment (DME) company and receives referrals from the practice.

A code-of-ethics statement should also be included in the policy, such as, “Our practice complies with all government regulations including data retention, documentation guidelines, medical-record confidentiality and other related business ethics.”

What Should Be Included?

Policies should be custom-designed. However, you should include some basics:

1. Employees must operate in compliance with state and federal laws and the policies and procedures of the practice.
2. Employees shall not engage in corrupt business practices or try to gain favorable treatment.
3. Employees shall not receive personal kickbacks from any entities for referring patients, or rebates in exchange for the purchase or sale of goods or services.
4. Employees shall not participate in false claims to payers or bill for unjustified or undelivered services.
5. Employees must avoid situations that may create a conflict of interest with their employer.
6. Employees shall report any wrongdoings or suspected wrongdoings to their supervisor or the management staff at their earliest opportunity.

The policy should also include statements such as:

• We strive to provide the highest quality of medical services that are appropriate, safe and in compliance with applicable laws, regulations and professional standards.
• We strive to treat every patient with respect, understanding that having an excellent reputation of integrity and caring for patient’s needs is our greatest asset.
• We strive to meet the healthcare needs of our patients and provide employment opportunities regardless of gender, age, disability, race, color, creed, religion or national origin.

The management of the practice should compile items that are particular to their practice and ask a healthcare attorney to review the policy. This may cost several hundred to several thousands of dollars, depending on the complexity. A normal policy for an individual or small group practice runs one to two pages. However, a large provider’s policy could be seven to 10 pages or more. It is prudent to spend the money, because a poorly constructed policy may prompt an OIG investigator to conduct a more comprehensive review.