Healthcare Compliance Guide: How to Create a Healthcare Compliance Program in 7 Easy Steps

It is dangerous to assume that because your practice is small that you don't need to have a healthcare compliance program. Any healthcare practice can become the target of a fraud investigation! nnWith just 7 easy steps, you can create a bona fide healthcare compliance program that will keep you and your practice safe… nnStep 1: Assess the areas of your practice that pose the greatest liabilities. To determine this, you will need to consider the following:

• Do you provide healthcare to patients who are either employees of the Federal Government who will be filing claims against/with their employers' carrier, or who will be filing claims under a government contract (e.g., Medicare/ Medicaid)?
• Do you accept Letters of Protection on 3rd-party liability claims?
• Do you have high employee turnover?
• Do you file your billing electronically?
• Do you out-source your collections?
• Do you contract with independent practitioners?
• Do you contract with outside vendors?
• Have any of your providers been sued for malpractice?
• What percentage of your billings are denied/reduced?
• Do you have a mechanism for responding to either denials or reductions in reimbursement?
• Do you provide ongoing training to billing and collections employees regarding CPT coding and ICD-9 coding?
• Do you perform background investigations on all employees prior to hire?
• Do you provide a mechanism for reporting complaints for internal resolution?

nnStep 2: Develop policies and procedures to allow management of each potential liability. To develop healthcare compliance policies and procedures, create a Compliance Manual that addresses areas of exposure to which attention must be directed to lessen the exposure arising in each area. This is one of the most critical areas of any compliance program, and should not be given short-shrift. You will also want to create an Employee Manual that lists employees' duties and responsibilities. It is recommended that the manual be tailored to your individual practice. nnStep 3: Delegation of Duties: Appoint a Compliance Officer who is qualified to oversee a healthcare compliance program. Role. The individual appointed must be someone who refuses to compromise the quality and integrity of the compliance program. Policies pertaining to billing, coding, documentation, etc. should be viewed as mandatory, not optional! nnStep 4: Create a Compliance Committee: Determine what departments within your practice should be represented on a Compliance Committee that your Compliance Officer will report to. Frequently, providers mistakenly conclude that the practice consists of only one department. Rarely would this be the case. Most practices will have, if nothing else, the following:

• Record keeping;
• Billingn
• Collectionsn
• Production.

Although one individual may wear hats for each department, it is best to consider these departments as discrete entities. This permits more effective management and analysis of your overall practice. nnStep 5: Design Hotline Protocol This protocol should be effective in providing a reporting mechanism for concerns/complaints arising either internally (i.e., employees) or externally (e.g., patients, insurance adjusters et al.). nnStep 6: Educate Your Employees on Correct Healthcare Compliance Policies and Procedures The policies/procedures contained in your healthcare compliance manual serve as an excellent educational tool for all employees and agents. However, to be effective, it is necessary for those policies and procedures to animate those with whom they are shared. Merely having a dormant document in which such policies/ procedures are contained will not accomplish your intended goal of developing a vibrant bona fide healthcare compliance program. You need to set a time and place for training session(s). It is important to conduct training in a manner most likely to capture the largest number of employees/agents for which the training is intended. nnStep 7: Set Up Disciplinary Procedures Setup disciplinary procedures to ensure licensed providers y are the individuals to whom boards of examiners will look for accountability. They are the ones law enforcement will look at as the instigator of abusive and unnecessary procedures. And, they are the ones governmental agencies will address inquiries into questionable/unusual practices. Unlicensed individuals must realize that their activities may also result in the accrual of personal criminal liability. Neither licensed nor unlicensed individuals are immune from prosecution. I was involved in one investigation in which a provider whose name was affixed to billing statements had been dead for more than six months. The office manager's sentence was actually longer than the doctors'.