Sampling of training program material for health care fraud, abuse and compliance training for health care providers. contact Chiropractic Compliance Consultants for more at 913-369-9000, or visit
Sampling of training program material for health care fraud, abuse and compliance training for health care providers. contact Chiropractic Compliance Consultants for more at 913-369-9000, or visit our website at cccpfc.com
Health care fraud is the intentional deception or (material) misrepresentation that could result in an unauthorized benefit or payment; whereas, abuse is practices that are inconsistent with accepted standards that could result in unnecessary costs to a health care program.
Current investigative interests for health care fraud investigators include multi-discipline practices, mobile labs, unlicensed rehab, improper coding, consultants, and not following the terms of payer agreements.
The “Anti-Kickback statute” is based on the premise that referrals not based on need may cause inflated costs to federal programs, may impair physician judgment, and may cause the quality of patient care to suffer.
Claims submitted for reimbursement represent not only the billed services/procedures but also that the services/procedures have been completely and accurately documented in the patient’s health care record.
It is imperative that all specialty diagnostic testing reports be signed and dated by the provider to indicate that the test was read by the provider and was used in the care and treatment of the patient.
Providers using CPT are instructed to pick the code that accurately describes the services/procedures performed; that are adequately documented in the patient’s medical record to support the specific codes reported.
Health care compliance is a system to detect and correct violations of law via a bundle of policies and procedures designed to identify legal and regulatory problems, correct identified misconduct, and create a mechanism to prevent future problems.
In determining to prosecute or not, the government will determine what remedial actions were taken by the organization or individual, such as implementing an effective compliance program, improving an existing one, etc.
Standards for compliance programs are found in the Federal Sentencing Guidelines (FSG), created by the United States Sentencing Commission as part of the “ Sentencing Reform Act of 1984 ” to provide uniformity and predictability in federal sentences by having culpability for an offense determined by steps taken to prevent and detect criminal conduct.
Standard One Compliance Standards & Procedures
The organization must have established compliance standards and procedures to be followed by employees and other agents that are reasonably capable of reducing the prospect of criminal conduct.
Access to all relevant laws, rules and guidelines
Consult competent legal resources
Develop compliance plan and program
Develop appropriate coding processes
Develop billing and auditing tools
Develop record retention
Develop confidentiality policy
Develop conflict of interest policy
Develop policy on gifts and gratuities
Adhere to payor requirements
Adhere to administrative practice standards
Establish expectations/accountability for all
Prevent inappropriate waivers of co-pays/deductibles
The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in illegal conduct.
Ensure conflicts interest are identified and disclosed
Include compliance in all job descriptions
Use compliance as element of job evaluation
Conduct background checks
Verify professional licensure
Include OIG/GSA sanction list in credentialing
Monitor OIG/GSA sanction lists for excluded
Monitor relevant State sanction lists
Conduct appropriate due diligence inquiries on vendors and agents
The organization must have taken steps to communicate effectively its standards and procedures to all employees and agents, e.g., by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required.
Disseminate relevant guidance material and fraud alerts to all
Communicate compliance information and educate staff on new compliance policies
Provide appropriate and consistent compliance training for all
Distill complex info into easily understood format
Ensure all understand obligation to accurately document activities
Ensure job descriptions are maintained, and that process in place for employees to understand job
Encourage all to follow spirit & letter of law
Encourage to seek guidance when in doubt
Participate continuing education programs
Monitor employee participation in on-going mandatory training
Standard Five Monitoring, Auditing & Reporting
The organization must have taken reasonable steps to achieve compliance with its standards, e.g., by utilizing monitoring and auditing systems reasonably designed to detect criminal conduct by its employees and other agents by having in place and publicizing a reporting system whereby employees and other agents can report criminal conduct by others within the organization without fear of retribution.
Evaluate contracts for conformity
Protect anonymity within legal and practical limits
Publicize reporting system
Assess for violations of laws & rules
Authorize independent investigations
Conduct organizational risk assessment
Conduct routine audits to monitor compliance
Develop/oversee internal reporting system
Identify & eliminate billing for services not rendered
Ensure business relations are appropriate
Ensure discounts are consistent with laws
Ensure referrals are not compensated
Listen to employee concerns
Evaluate incentive structure
Monitor for upcoding, not medical necessary
Substantiate accuracy of info and reports
Standard Six Consistent Enforcement/Discipline
The organization must have consistently enforced the standards through appropriate disciplinary mechanisms, including as appropriate, discipline of individuals for the failure to detect an offense.
Ensure organization has well defined and publicized enforcement and discipline policies
Include compliance violations into established disciplinary programs
Take disciplinary action when noncompliance is substantiated
Discipline proportionate to violation
Flexible discipline to account for mitigating or aggravating circumstances
Discipline consistent with policies and procedures
Discipline consistently enforced at all levels
Document recommend disciplinary action
Coordinate with management functional areas to ensure appropriate discipline is taken
Take appropriate actions with individuals excluded from governmental program
The organization, after an offense has been detected, must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses – including any necessary modifications to its program to prevent and detect violations of law.
Communicate noncompliance through appropriate channels
Develop corrective action plans in response to noncompliance, & monitor for effectiveness
Incorporate any necessary changes to reduce risks
Respond to inquiries promptly, thoroughly and discretely
Institute policies/procedures and education to respond to identified problems or vulnerabilities
Cooperate with government inquiries / investigations
Participate in payor audits
Investigate matters related to noncompliance
Maintain accurate/complete records on investigations
Negotiate with external regulatory agencies
Disclose overpayments to payers
Coordinate disclosure with legal counsel
Identify recipient/process for voluntary disclosure
Understand applicability of attorney-client privilege