Why Does My Medical Practice Need a Compliance Plan?
If your medical practice accepts Medicare or Medicaid patients, you might think this question is moot. After all, you’re already required to participate in annual compliance training, you as well as all of your downstream entities (subcontractors). While your training ensures that everyone “knows” what to do and that your practice is compliant with knowing best practices, it does not ensure that these guidelines are implemented.
You Might Be at Risk and Not Realize It
Most physicians and health care professionals today enter health care in order to provide high quality medical care to their patients. The majority strive to work ethically, provide the best care, and cooperate with laws and policies around payment. The last thing on your mind is taking advantage of the system or your patients. Certainly, the last thing you want to learn is that you or your staff have coding errors, improper documentation, have over or underutilized a service or have adopted inappropriate referral practices.
Unfortunately, a small number of healthcare professionals do exploit the health care system through fraud and abuse, a situation which puts pressure on everyone else to be that much more scrupulous. The truth is that even if your practice isn’t intentionally abusing the system or knowingly being fraudulent, you may still be doing one or both. Moreover, your practice may be guilty of a “lesser evil”—waste.
Learn more about identifying fraud, waste and abuse and download the CMS Physicians Fact Sheet (July 2014) by clicking here.
Stop Playing it “Safe”
Take for example, the practice of undercoding services “just to be safe.” Some physicians, fearful of fraud and abuse, decide to play it safe by undercoding their Medicare patient visits. However, undercoding is also a problem because it not only decreases earned revenue (that you ought to be getting reimbursed for), but it also establishes false utilization patterns. These patterns are very carefully monitored not only by payers but also by the Federal government. The truth is that undercoding can flag your practice as an outlier and can lead to an investigation.
This example is just one of many in which well-meaning physicians operate outside their knowledge base in order to stay above board, but end up achieving the very opposite effect. In today’s health care environment, physicians have less and less time to navigate the ins and outs, but a shortage of time and resources won’t save you from being penalized, investigated, and worse case, losing your practice, license or even being put in jail.
It’s Up to Health Care Professionals to Make the Right Choices
While many maintain that the Federal Government inherently distrusts physicians, the truth is that they have placed an enormous amount of trust in physicians. Federal health care programs like Medicare and others absolutely rely on health care professionals to provide quality health care and appropriate services in every case. They also rely on physicians to submit accurate and truthful claims information as they apply for reimbursement covered by Medicare.
However, what many practices are missing is an internal plan to ensure your practice is compliant, a plan from leadership down that ensures everyone in your practice not only knows (has the training) but also follows the guidelines you outline in order to stay legal.
What a Compliance Plan Does for Your Practice
Establishing and following a compliance program will not only help you as physicians and your staff avoid fraudulent activities, it will also safeguard you against submissions of false or inaccurate claims—accidental or otherwise.
What a Compliance Plan Looks Like
As a medical practice owner or operator, you need to ask the question Do we have the internal processes to support our compliance with all Medicare Compliance Program requirements? Other questions you should ask include:
- Does everyone in the medical practice know what to do if we think we have a problem?
- Does our practice know how to voluntarily disclose self-discovered evidence of potential fraud?
- Does our practice know what do to with information they have about fraud and abuse against Federal health care programs?
- Do our physicians understand how to comply with Federal laws by identifying “red flags” that could lead to potential liability in law enforcement and administrative actions?
If you aren’t sure as you think through these questions, or even if you believe that you know the answer, the test of whether you are prepared is whether or not you have developed and currently utilize an up-to-date internal compliance program.
The following seven steps, as developed by the Medicare Learning Network, powered by the CMS (the Center for Medicare and Medicaid Services), is a picture of what a compliance plan might look like in your practice:
- Conduct internal monitoring and auditing
- Implement compliance and practice standards
- Designate a compliance officer or contact
- Conduct appropriate training and education
- Respond appropriately to detected offenses and develop corrective action
- Develop open lines of communication with employees
- Enforce disciplinary standards through well-publicized guidelines
If you have not developed and currently utilize an internal compliance plan when it comes to Medicare, you may be at high risk for committing fraud, waste or abuse. Don’t let another minute go by without ensuring that you close that gap.
United Physician Services can help. With over 30 years of experience working with medical practices and physicians nationwide, we can identify solutions for you and work alongside you to implement, keep you 100 percent in compliance and maximize your revenue in the process.