OIG Compliance Program for Individual and Small Group Physician Practices
Providers who treat patients on Medicare or Medicaid need to comply with the Patient Protection and Affordable Care Act of 2010. According to the Office of Inspector General, providers individual and small group physician practices must develop compliance programs that address the following:
- Conduct internal monitoring and auditing
Periodically (at least once a year) assess the standards established, how employees are carrying out their responsibilities, and whether claims for payments are accurately coded and services billed are medically necessary.
- Implement compliance and practice standards
Determine the types of fraud and abuse issues that might arise in your practice. Review the OIG work plan and semiannual report to identify risk areas. According to the OIG, the 4 most common risk areas include: (1) coding and billing, (2) “reasonable” and “necessary” services, (3) documentation and (4) improper inducements, kickbacks, and self-referrals. Once you have identified the risk areas, identify employees and expectations for each area, and clearly state them in your practice’s code of conduct
- Designate a compliance officer or contact
There should be a mechanism for ensuring standards of conduct, policies and procedures, laws and regulations are being followed. If you are unable to appoint a designated compliance officer, the OIG suggests distributing oversight responsibilities among several employees (e.g., the office manager and the primary billing person).
- Conduct appropriate training and education
Effectively communicate the established standards to your staff. Make your staff aware of the basic risk areas and their role in ensuring compliance. It should also be clearly communicated that their compliance is a condition of their employment.
- Respond appropriately to detected offenses and develop corrective action
Your compliance program should require that detected misconduct being promptly corrected. That includes the timely reporting and reimbursement of overpayments to Medicare or Medicaid. Your compliance program should also include a detailed process for conducting internal investigations of reported violations.
- Develop open lines of communication with employees
Employees must be enabled to report fraud and other misconduct without fear of retaliation. Typically this can be done by establishing an anonymous hotline. However, for smaller practices an anonymous drop box may be an alternative, or an open door policy between physicians, compliance personnel, and employees.
- Enforce disciplinary standards through well publicized guidelines
Ensure that the disciplinary standards are consistent and appropriate based on the violation. Employees who fail to detect or report fraud or other violations should also be subject to disciplinary standards.
While developing a compliance program is voluntary, establishing and following an effective compliance program helps providers:
- Avoid fraudulent activity
- Increase the accuracy of medical and billing information
- Defend against any charges the practice violated the False Claims Act, the Stark self-referrals. anti-kickback statutes, and other federal laws
- Decrease the odds of an HCFA (Health Care Finance Administration) or OIG audit
- Show they are acting in good faith to properly submit medical billing claims
- Provide guidance to the staff on proper billing procedures
- Have a program in place informing employees of their ethical duty to report fraud
For more information on compliance programs for physicians, see OIG’s “Compliance Program Guidance for Individual and Small Group Physician Practices”