7 Steps To A Compliance Program By: MedSafe


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Are you looking to build a compliance program within your practice? check out this presentation on the 7 steps and give us a call when your ready! www.MedSafe.com (800) 255-6387

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  • Number of hours of training will depend on individual employees job responsibilities
  • There may be other functions to monitor or audit depending on the type of organization
    Audits may be Retrospective of Prospective
  • How do employees report possible compliance misconduct? Hotline?
  • OIG requires prompt reporting of misconduct to the appropriate governmental authority within a reasonable time, but not more than 60 days. When does 60 days begin?
    Corrective action plan
  • 7 Steps To A Compliance Program By: MedSafe

    1. 1. The Important Components of a Corporate Compliance Program By: Laurie Aloi, CPC, CHC MedSafe “The Total Compliance Solution”
    2. 2. 7 Elements of a Compliance Program 1. 2. 3. 4. 5. 6. 7. Standards of Conduct/Policies and Procedures Compliance Officer/Compliance Committee Education Monitoring and Auditing Reporting and Investigating Enforcement and Discipline Response and Prevention
    3. 3. #1 Standards of Conduct/Policies and Procedures  Code of Conduct:  Promote your commitment to compliance  Demonstrate your organizations attitude and emphasis on compliance and its applicable laws and regulations  Build your program around these elements  Code of Conduct is meant for all employees, representatives of the organization, vendors, suppliers, independent contractors, board members and volunteers
    4. 4. #1 Standards of Conduct/Policies and Procedures  Policies and Procedures:  Begin with areas of risk identified within the OIG workplan:  Internal assessments  Self Disclosure  Regular Medicare sanction checks  Billing Policies  Unbundling  Credit Balances  No charge visits  Incomplete/un-successful surgical procedures
    5. 5. #2 Compliance Officer/Compliance Committee  “Serves as the focal point for Compliance activities”  “Appropriate authority is critical to the success of the program”  Most Compliance Officers/Committees report to the CEO or the Board
    6. 6. #2 Compliance Officer/Compliance Committee  The Compliance Officer/Committee will:  Oversee and monitor the compliance program  Report to the governing body, CEO  Revise the compliance program periodically  Develop the education and training program  Assist with internal compliance review and monitoring  Independently investigate and act on matters related to compliance
    7. 7. #3 Education  The most important line of defense for a Compliance Program!  The OIG recommends that all employees be required to have a specific number of hours of training annually.
    8. 8. #3 Education  Ten elements to include in a basic compliance training program:       Body of legal and regulatory knowledge guiding compliance activity Organizations compliance philosophy How to handle compliance communication inside and outside your organization How to define and report compliance violations Policies regarding patient confidentiality and the handling of patient information Claims submission
    9. 9. #3 Education  Ten elements continued:     Only qualified personnel may perform diagnosis and procedure coding Physician documentation is the primary determination for claims submission Vendors are held to the same compliance standards as staff Employees involved in compliance violations will be disciplined
    10. 10. #3 Education  Corporate Officers, Managers and other staff should receive Ethics training that includes the following:          Government and private payer reimbursement principals General prohibitions on paying or receiving remuneration to induce referrals Proper confirmation of diagnosis Submitting claims for physician services when rendered by a nonphysician Signing a form for a physician without the physicians authorization Alterations to medical records Prescribing medications and procedures without proper authorization Proper documentation of services rendered Duty to report misconduct
    11. 11. #4 Monitoring and Auditing  Ongoing evaluation is critical to a successful compliance program  Functions common to all organizations that should be reviewed;         Anti-kickback and self referral issues Credit balances Bad debts Claim development and submission Record retention Cost reporting Marketing Compliance program process
    12. 12. #5 Reporting and Investigating  The OIG stresses the importance of communication: “An open line of communication between the Compliance Officer and personnel is equally important to the successful implementation of a compliance program and the reduction of any potential fraud, abuse and waste.”
    13. 13. #5 Reporting and Investigating  Policy for no retaliation or retribution. If not, this may create whistleblowers  Confidentiality and anonymity in the reporting process  All complaints and investigations are monitored and tracked
    14. 14. #6 Enforcement and Discipline  Compliance program should include a written policy setting forth the degrees of disciplinary actions that may be imposed for failure to comply with standards  The policy should include the following 5 points 1. 2. 3. 4. 5. Non-compliance will result in discipline Failure to report non-compliance will result in discipline An outline of disciplinary procedures A list of the parties responsible for appropriate action A promise that discipline will be fair and consistent
    15. 15. #7 Response and Prevention  Violations of compliance programs threaten an organizations status  Failure to respond, or to engage in lengthy delay can have serious consequences  If a problem is found the first step is to meet with your legal counsel to determine the severity and develop a plan of action  OIG requires prompt reporting to the appropriate authority within a reasonable time, but not more that 60 days
    16. 16. #7 Response and Prevention  Thorough documentation of the investigation must be available         Description of the potential misconduct and how it was reported Description of investigative process List of relevant documents reviewed List of employees interviewed Employees interview questions and notes Changes to Policies and Procedures, if appropriate Documentation of disciplinary actions, if any Investigations final report with recommended actions  Voluntary Disclosure