7. Enforcement through discipline. The practice should publicize to employees its disciplinary standards, document findings of noncompliant conduct, and be prepared to issue sanctions to violators. Disciplinary actions can include reprimands, probation, demotion, suspension, and even termination and referral for criminal prosecution. The task gets especially tough when a physician is suspected. "Even if the person is an owner-partner, you need to take direct action," Ruggio says. "If you don't step up, you could be seen as a conspirator in a potential false claims act — the last thing you want to do."
A small but growing number of practices are developing new compliance plans or revising old ones in advance of more specific regulations from the government. Townsend says his firm has already seen an upswing in requests from medical practices seeking help to revisit compliance plans or develop new ones.
"There's just so much more talk about it now and it's also fed by payers getting more aggressive with audits of practices' documentation, coding, and billing," he says.
A successful compliance plan sends a message to the staff, physicians, payers, and regulators that the practice is trying to prevent errors.
Put it together
The seven elements described above were first published in the Federal Register in 1998, and experts have long advised practices to develop and follow compliance programs based on them. Although the reform law raises the stakes by beefing up enforcement of existing compliance rules, it would be wrong to say that practices should think about billing compliance only because of the ACA. A good compliance plan not only reduces the risk of costly False Claims Act allegations, it also reduces vulnerability to coding errors generally, as well as Stark violations and other risks.
"Compliance is the biggest risk area for physician practices, followed closely by the risk of thinking it is an unnecessary cost area," says Jim Hook, director of consulting services and principal with The Fox Group, based in Upland, Calif. "We don't have final rules for what physician compliance plans will look like yet, but they will come and so will enforcement, so it's better to start sooner than later."
Saner observes that few small and midsize practices have compliance officers, compliance committees, outside coders doing periodic claims audits, 24-hour-a-day reporting hotlines, and other elements of the full-blown compliance plans seen at large practices, hospitals, and academic medical centers.
"It has nothing to do with anyone's desire to not be compliant," Saner says. "It's just a matter of resources. Small practices are under a tremendous administrative burden from Medicare and private managed-care plans. They've got their hands full just getting through the day."
Perhaps, as Saner and other experts we contacted suggest, it's best to view compliance plans as preventive medicine to minimize mistakes that could end up costing much more than maintaining the plan. And, if the plan helps to increase accuracy in documentation and root out billing and coding problems, it could enhance the delivery of patient care and improve your practice's bottom line.
A "living, breathing" plan
The OIG’s guidance to individual and small physician practices emphasizes that compliance plans must be active programs: "Compliance programs are not just written standards and procedures that sit on a shelf in the main office of a practice, but are an everyday part of the practice operations. It is by integrating the compliance program into the practice culture that the practice can best achieve maximum benefit from its compliance program."