Medicare Compliance & Reimbursement

Tip: Manage and mitigate your risks accordingly.

If your practice is struggling to stay afloat from pandemic fallout, compliance planning may very well be at the bottom of your to-do list. However, an uptick of enforcement activity suggests the feds are ramping up for a banner year, and now may be a good time to invest in compliance planning before audits escalate.

Why: Two main goals for any compliance program include maintaining compliance and surviving a potential audit. So it’s in your practice’s best interest to make the investments in time, money, and other resources now to put a compliance program in place — or to revamp what you’ve already established — that achieves those goals.

“Maintaining compliance requires an ‘all hands on deck’ attitude, and a written plan that details exactly how staff will promote accuracy and ethical processes,” says Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast in Laguna Niguel, California.

Caveat: However, achieving compliance may be especially tough right now as employees are feeling burned out personally and professionally, and may not be performing at their best.

Plus, on top of COVID-19 wreaking havoc on the healthcare industry, the feds have remained steady with their enforcement efforts instead of reeling them back as many assumed they would.

Incorporate These 5 Components

Right now, the HHS Office of Inspector General (OIG) and the Department of Justice (DOJ) are homing in on COVID-19- related issues. But that doesn’t mean the federal enforcers have slacked off other fraud and abuse crimes.

The combination of heightened state and federal scrutiny, provider confusion, and the COVID-19 public health emergency (PHE) make for a perfect storm. And that’s why comprehensive compliance planning and training are more critical than ever to circumvent controversy and sidestep fraud.

Take a look at five important measures to boost your compliance planning efforts:

1. Pertinent laws and regulations: A government audit would look at whether you address specific laws or specific behaviors with your staff or ancillary agents, said Beverly Smith, JD, CSSMBB, CPCO, in an AAPC 2020 Virtual HEALTHCON session “Guidelines on How to Demonstrate a Compliance Plan’s Effectiveness.”

To survive a government agency audit, the easiest way is to describe a scenario and then point out: “This is a violation of HIPAA, this is a violation of HITECH, this is a violation of [the] Stark Law,” Smith said.

Top tip: Writing about the policies specifically is also a good way to make sure you remember to update them when necessary, Smith said. For example, if the Stark Law undergoes any changes after the public comment period, then you’ll know exactly which parts of your policies and procedures you’ll need to update accordingly.

2. Training: Make sure you incorporate staff continuing education — including for physicians and other clinicians — into your compliance program, Fletcher says. You want to make sure there is at least one annual compliance training, as well as training focused on promoting increased billing and coding accuracy, she recommends.

3. Language and wording: Smith said that many plans add too much legalese or industry-specific jargon, but compliance programs and plans are usually presented to staff who are onboarding and may not know the acronyms your organization uses regularly or even the definition of some industry-specific words. Write the policies simply enough so the least knowledgeable person in the room can walk away with an understanding of the rules without having to ask any clarifying questions, she recommended.

4. Misconduct: Be explicit in stating what counts as misconduct, too, Smith said. “Stating plainly what is misconduct is sometimes the biggest thing that we have to do.” Being explicit is helpful because ambiguous words or phrases can leave crucial aspects of compliance open to interpretation, which is risky and doesn’t hold everyone to the same level.

5. Checklist: “Inventory” your compliance obligations, Smith proposed, so staff know exactly what to do to achieve and maintain compliance. With the ongoing COVID-19 pandemic, now is a good time to make sure your compliance plan addresses policies like telemedicine and working from home, too.

Self-Audit Your Compliance