Podiatry Coding & Billing Alert

Having an effective compliance program can not only prevent mistakes from occurring but also mitigate penalties in the event that you do commit infractions. Here are tips for how to implement CMS’s Seven Fundamental Elements of an Effective Compliance Program from CJ Wolf, MD, CHC, CPC, CCEP, CIA, COC, Senior Compliance Executive for Salt Lake City-based Healthicity.

1. Implement written policies, procedures and standards of conduct.

You must have a written code of conduct. “Let’s assume you’re already avoiding compliance issues,” Wolf tells Podiatry Coding & Billing Alert. “The first thing you need to do for billing mistakes is explain what should happen in the instance that they occur.”

Assert your general approach to compliance, and then be more specific with statements like “we don’t waive copays.”

2. Designate a compliance officer and compliance committee.

“(CMS) is reasonable here,” says Wolf. “The need (for a compliance officer) is based off of your organization’s size, so no need to run out and hire one. For many practices, your practice manager can also serve as your compliance officer.”

However, you have to specifically delegate this duty and your staff need to know who this person is. Larger practices should have a committee, typically composed of “a high-level group” like partners and senior officers.

3. Conduct effective training and education.

“Well, no one ever taught us this” isn’t an excuse.

“Your doctors need to feel comfortable,” Wolf says of their compliance competence. “There needs to be a program in place to provide training.”

Wolf notes that each job may require uniquely focused training. For example, a coder’s compliance training will differ from a physician’s.

4. Develop effective lines of communication.

“What OIG and others want to see is that having provided guidelines you also have a way for anyone to report concerns,” Wolf says, suggesting a reporting hotline. “You must have something safeguarding your program and must have some mechanism for taking action and reviewing concerns.”

“In the case of whistleblowers, most want the issues they report solved, but then get pushback,” Wolf says, emphasizing the need for open lines of communication. Make sure that your employees have an avenue for reporting their concerns.

5. Conduct internal monitoring and auditing.

“Take some sort of proactive measures and activities to catch it,” Wolf says. Develop some resources into proactive monitoring of billing, HIPAA compliance, and how copays are being collected.”

You can conduct internal audits if it’s feasible for your practice, while outsourcing may be more effective for larger organizations.

6. Enforce standards through well-publicized disciplinary guidelines.

“They (CMS) expect to see that when mistakes are made or policies broken there’s a history of documented action,” Wolf says of following up on mistakes. It’s not enough to simply acknowledge mistakes were made, though firing employees for first-time offenses is not necessary.

7. Respond promptly to detected offenses and undertaking corrective action.

“Sometimes honest mistakes are made,” Wolf says. “But if you look under a rug and find a pile of dirt, you have to clean it up. If a billing error happens from the result of a glitch, you can’t just identify it — you have to also fix the issue that caused a problem.”

Identify the person at the root of the problem. “You have policies, education, audits, and are generally setting yourself to find things that are wrong. And now that you’ve found it out, you have to fix the mistake.” Treat the disease, not the symptoms.

Visit https://oig.hhs.gov/compliance/provider-compliance-training/files/compliance101tips508.pdf to read the OIG compliance program tips.