Pathology/Lab Coding Alert

Take 7 steps now to meet ACA standards.

Making sure your compliance plan is in place should top the list of your lab’s New Years’ resolutions — your Medicare and Medicaid program enrollment could depend on it.

Here’s why: The Affordable Care Act (ACA) will require a compliance program as a condition of continuing enrollment in Medicare or Medicaid, said Lauren Gillooly Robbins, manager for provider education support services with Palmetto GBA during CMS’s recent webinar, “Affordable Care Act Provider Compliance Programs: Getting Started.”

Although CMS has not yet established an implementation date for this requirement, you shouldn’t wait and get caught unprepared. Instead, read on to learn seven actions that CMS and the OIG recommend that you can start now to be on top of your compliance plan, as outlined by Julie Taitsman, MD, JD, chief medical officer with the OIG, during the webinar.

Bonus: Even before the ACA requirement kicks in, a sound compliance plan ensures that you’re reporting your services ethically, and that you have fewer billing mistakes. This will ultimately lead to faster claims payment and less scrutiny from auditors, Robbins said.

Step 1: Write Policies and Procedures

The best way to clarify and share your lab’s compliance plan is to put it in writing. “These written policies, procedures and standards should be composed with guidance from the compliance officer and compliance committee,” Taitsman said. All employees should review the standards within 90 days of being hired and then annually thereafter, she advised.

The written compliance plan should include your lab’s code of conduct, commitment to compliance, and treatment of patients and employees, she said. In addition, the plan should outline the compliance responsibilities for all of your staff members, as well as the following items, Taitsman said:

• Employee training plan
• Reporting mechanisms for suspected non-compliance
• Investigation procedures
• Compliance problem resolution methods
• Compliance plan update procedures
• Auditing plan to track compliance

Tip: Make the plan easy to read and concise to entice more participation. “Fancy does not impress anyone if the plan sits on a shelf or in a computer file,” said Jacqueline Bloink, CPC, a consultant with Coding Continuum, Inc. and compliance director for a provider group in Arizona, during CMS’s webinar.

Step 2. Plan Continuing Oversight

Once you’re written the compliance plan, your work is not done—in fact, it’s just beginning. You should put in place a compliance officer and/or compliance committee to oversee the program, according to Taitsman.

These employees should create policies and procedures, attend staff meetings, monitor compliance performance, enforce standards and evaluate corrective actions.

Step 3. Train and Educate Staff

Training your staff is one of the most important elements of your compliance plan to ensure that everyone is aware of the expectations and standards.

“Training should, when appropriate, use actual compliance scenarios and/or investigations of non-compliance as examples of risks that employees and managers may encounter,” Taitsman said.

Step 4. Open Lines of Communication.

Encouraging your staff members to speak up if they see a compliance issue is essential for any effective program, Taitsman says.

You can create reporting mechanisms like an email or internet-based form, an anonymous drop-box, or an in-person appointment. No matter what you choose, you should make sure that every staff member knows the reporting method so they can quickly access it when necessary.

Step 5. Audit and Monitor the Plan

Monitoring refers to regular, daily reviews to confirm that your operations include ongoing compliance. Auditing, on the other hand, “includes formal compliance reviews with a particular set of standards as base measures,” Taitsman says. During audits, your compliance staff evaluates the compliance program via on-site visits and internal and external examinations, and formally reports the findings. You should perform auditing at least once a year, or more often as appropriate, she advises.

Common problematic compliance areas include coding and billing errors, as well as hiring people who are statutorily excluded from participating in federal programs like Medicare and Medicaid, Taitsman says.

6. Apply Consistent Discipline

If you find anything amiss during your monitoring and auditing activities, you’ll need to have a plan in place that enforces discipline in a timely and consistent manner, Taitsman advises. “Disciplinary policies must be clearly written and describe expectations and consequences for non-compliant behaviors. They should be widely publicized and reviewed at least annually for the staff.”

7. Implement Corrective Action

At some point during your tenure under a compliance plan, you’re sure to find an issue, and you must have a plan in place to correct it. For instance, you may need to refund an overpayment you’ve identified, or create a disciplinary action against non-compliant employees. Ensuring that you follow through with the corrective action is the final step to confirm that your compliance plan is solid.

Resources: The OIG provides resources to help you craft compliance plans according to government guidelines, such as, https://oig.hhs.gov/authorities/docs/cpglab.pdf. Also, the government’s Health Care Fraud Prevention and Enforcement Team, also known as HEAT, offers free fact sheets, webinars and other reference materials that can guide you, as can the webinars within the CMS library. Finally, you can access a special OIG fraud alert regarding lab payments to referring physicians at http://oig.hhs.gov/fraud/docs/alertsandbulletins/2014/OIG_SFA_Laboratory_Payments_06252014.pdf.