1. B Y : A N D R E A A N S E L M E & C A R L Y B E T H E A
WILLOW CREEK PHYSICIAN OFFICE
COMPLIANCE PLAN
2. COMPLIANCE PLAN OBJECTIVES
• Prevent submission erroneous and combating
fraudulent conduct
• Use of internal controls
• more efficiently monitor adherence to applicable statutes,
regulations and program requirements
• Prevent violations of company policies
www.oig.hhs.gov
3. CODE OF ETHICAL CONDUCT
• Law abiding
• Compassion
• Diversity
• Excellence
• Honesty
• Commitment
4. COMPLIANCE COMMITTEE
Members
Mary Anderson, Ph.D., MS, RHIA, CMCO Compliance
Officer
Henry Johnson, RHIA Health Information
Manager
Megan Phillips, FNP-BC Family Nurse Practitioner
Sarah Young, JD Healthcare Attorney
Jeff Clark, MD Family
Physician
Duties
1.Have general knowledge about
compliance and quality issues within
Willow Creek Physician Office.
2.Attend quarterly meetings to monitor
progress and effectiveness of
compliance plan.
3.Recommend improvements for areas
lacking in compliance and make
necessary changes.
4.Ensure consistent communication
throughout the office by educating
staff on compliance issues,
improvements, and clarifications.
6. BILLING
Policy:
Willow Creek Physician Office should
follow all federal regulations regarding
billing. Quarterly reviews will be
completed to guarantee compliance
with our policy. All billing is required to
be accurate and truthful; no staff
member should ever misrepresent
charges on behalf of third party
payors.
Procedure:
• Prevention of Billing Items and
Services not Provided to Patients
• Prevention of Claims that are not
Reasonable and Necessary
• Prevention of Billing that is
Duplicated or for Non-Covered
Services
• Prevention of Misuse of Provider
Identification Numbers
7. CODING
Policy:
Willow Creek Physician Office
complies with the federal
regulations. Employees will
maintain a high level of
professionalism and ethical
behaviors while performing these
procedures. Adherence to these
guidelines is essential.
Procedure:
• Prevention of Unbundling Billing
Components
• Proper use of Coding Modifiers
• Prevention of Clustering and Up
Coding
• Abide by Coding Regulations
8. DOCUMENTATION
Policy:
Willow Creek Physician Office
should guarantee timely,
accurate, and complete
documentation to improve the
quality of clinical patient care.
Documentation should comply
with the Federal Register. Proper
documentation habits are
necessary to receive full
reimbursement from the third
party payor.
Procedure:
• Prevention of untimely
documentation
• Prevention of incomplete,
inaccurate, and illegible
documentation
• Ensure CPT and ICD-9 CM codes
are used for claim submissions
and are supported
• Appropriate use of the HCFA
1500 form
9. IMPROPER INDUCEMENTS, KICKBACKS,
AND SELF-REFERRALS
Policy:
Willow Creek Physician Office
is committed to maintaining
high ethical standards and
ensuring that physicians are
complying with all applicable
laws pertaining to the Anti-
Kickback law. Our facility
interacts with several
physicians to provide high
quality care to our patients
through adhering to this law.
Procedure:
• Prevention of inducements,
kickbacks, self-referrals, and
soliciting
• Prevention of financial
arrangements with outside entities
and joint ventures entities supplying
goods or services
10. EDUCATION & TRAINING
Topics Covered:
• Job analysis of specific duties
pertaining to job title
• Availability of online resources
• Technical support for
unexpected occurrences or
concerns
• Awareness of upcoming
changes
• Information about future CE
events
• CMS newsletters
Seminar information:
• Risk Area
• Core Values
• Staff Compliance
• Quality Improvement
• Patient Service Improvements
Requirements:
• 90% or above score on required
assessment
• Second attempt allowed
11. DISCIPLINARY GUIDELINES
• Step one: Level I Reminder is a verbal warning
• Step two: Level II Reminder is a written warning that
is recorded in employee file
• Step three: A Decision-Making Leave is the final
chance- written essay is required
• Violator Removal: Immediate termination for
violation of HIPAA and federal laws, fraudulent
behavior, and illegal actions
12. AUDITS
• Take place once during each fiscal year
• Occur at random
• Problem identified
• More extensive and frequent audits will occur
• Root cause analysis
