How to Write an Effective and Powerful Compliance Plan

Posted on 13 Jul, 2018 |comments_icon 0|By Elizabeth
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How to Write an Effective and Powerful Compliance Plan

What is a compliance plan?

A compliance plan is a collection of steps that a provider, organization, or practice establishes to ensure adherence to federal and state regulations. OIG developed voluntary compliance program guidance in an effort to help organizations with their compliance programs. Resources can be found at www.oig.hhs.gov. These resources assist in setting the foundation to an effective program.

In 2003, OIG developed Compliance Program Guidance for Pharmaceutical Manufacturers. In this document, there were seven elements for an effective compliance program. Although the document was directed towards pharmaceutical manufacturers, the elements can be used as the framework for any specialty. The elements include:

  1. Implementing written policies and procedures
  2. Designating a compliance officer and compliance committee
  3. Conducting effective training and education
  4. Developing open lines of communication
  5. Conducting internal monitoring and auditing
  6. Enforcing standards through well-publicized disciplinary guidelines
  7. Responding promptly to detected problems and undertaking corrective action

An effective and successful compliance plan should outline each of these seven elements and include directions, standards, and policies for how each element will be handled.

If an area of non-compliance is found, detailed records of the incident or misconduct should be documented with the date, name of the person that reported the issue, the person who initiated action on the issue, and any corrective or follow-up action that was taken.

The Federal Register Vol. 65 No. 194, published on October 5th, 2000, outlined Compliance Program Guidance for Individuals and Small Group Physician Practices. This document can be found at www.oig.hhs.gov. This document details the risks and benefits to a compliance program.

Some of the possible risk areas for physicians and physician practices include documentation, federal regulations noncompliance, coding and billing issues, and medical necessity issues.

Below are a few points from each category:

  • Documentation
    1. Timely, appropriate, accurate and complete medical documentation is essential to clinical patient care
    2. Equally important to coding and billing for services rendered
    3. Vital to continuity of care
    4. One of the most important aspects of compliance
  • Improper inducements of kickbacks and self-referrals
    1. Encourages compliance by setting forth standards and procedures
    2. Medical decision making can be distorted, services may be over-utilized, costs can be increased if Anti-kickback and Self-referral laws are violated
  • Billing and coding
    1. Discourage unbundling
    2. Improper modifier usage
    3. Upcoding and downcoding
    4. Double billing or duplicate billing
    5. Billing for services not rendered or that are not medically reasonable or necessary
  • Medically necessary and reasonable services
    1. Claims may be denied based on a lack of medical necessity
    2. Services must meet predefined requirements for medical necessity and services that are reasonable

Compliance Program Benefits

Compliance programs and plans have many benefits if they are implemented and adhered to in a consistent manner. An organization that is aware of their compliance plan usually finds fewer billing and coding mistakes, their documentation accuracy improves, and their chances for a government audit decreases.

Ensure that compliance plans address the issues specific to the organization or provider. No two compliance plans will be alike since they should be tailored to the individual provider, practice, or organization. Make sure that auditing is a major part of the compliance plan and that an auditor can review an organization’s compliance plan. Furthermore, provider education should incorporate issues set forth in the compliance plan.

Tip: OIG developed CPGS for many healthcare entities!

Learn More

Learn how to identify and correct coding problems before government and private payers to call foul with TCI’s best-selling Master Auditing Basics 2018 —updated for 2018 with the latest billing, coding, and compliance regulations and requirements.

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Elizabeth


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