Medicare Compliance & Reimbursement

Enlist expert help to establish a compliance plan for both Medicare and Medicaid.

The Affordable Care Act (ACA) may bring changes to your practice's accountability, particularly where compliance plans are concerned. It's not too early to start researching the components you'll need to include to survive official scrutiny and protect you from accusations later.

Background: Although the ACA touches on the importance of compliance plans, those plans are still optional at this point. However, that may not be the case forever. "Under the ACA, a compliance plan that has the 'core elements' which will be established by the Department of Health and Human Services and the Office of Inspector General will become a requirement," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. "This is a huge change. First we will need to find out what the core elements will be."

In addition, compliance requirements will impact your Medicaid patients as well, says Scott A. Memmott, Esq., with Morgan, Lewis & Bockius, LLP in Washington, DC. "State Medicaid plans must require providers and suppliers to establish a compliance program that contains the same core elements that HHS, in consultation with HHS-OIG, eventually will establish with respect to the Medicare program," Memmott says. Therefore, even doctors who see no Medicare patients but do see Medicaid patients will be subject to mandatory compliance program requirements that will come from their state Medicaid plan, he adds.

The Department of Health and Human Services will likely be developing the compliance program's elements over the next year or more, but in the meantime, you should continue to pursue your practice's compliance objectives by creating a compliance plan tailored to your needs. The following tips can give you an edge.

Start With the OIG's Seven Components

The OIG outlines seven components that your compliance plan should include -- and offers special guidance for hospitals, third-party billing companies, and small private practices (you can access this information online at oig.hhs.gov/compliance/compliance-guidance/index.asp).

According to the OIG, every compliance plan should incorporate and build on seven basic directives:

1. Conduct internal monitoring and auditing.

2. Implement compliance and practice standards.

3. Designate a compliance officer or contact.

4. Conduct appropriate training and education.

5. Respond appropriately to detected offenses and develop corrective action.

6. Develop open lines of communication.

7. Enforce disciplinary standards through well-publicized guidelines.

Resources: You might enlist the help of your practice's attorney at some point during the compliance plan drafting process. Getting a legal expert's input and final approval will ensure you haven't overlooked any important elements -- and bolster your plan's legitimacy.

In addition, you can hire a healthcare management consulting firm specializing in compliance plans to write your entire compliance plan or to offer legal advice. The more specialized your practice is and the more ancillary services you offer, the more help you're likely to need to make sure your compliance plan covers all your liability areas.

If your practice belongs to a healthcare specialty society, this may be an excellent resource to tap into. Societies may have customized templates and other data useful for creating a specialty-specific compliance plan.

Avoid Cookie-Cutter Compliance

At all costs, you should avoid downloading or purchasing a cookie-cutter compliance plan that only requires you to fill in the blanks with a few practice details. If your compliance plan isn't customized to address the unique details of your office's billing practices, the document will not be a useful source of guidance for billers and physicians. A cookie-cutter plan quickly purchased and stuffed on the shelf won't help you prove your commitment to compliance.