Pulmonology Coding Alert

In June, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued a draft guidance to help physicians in solo or small group practices conduct effective voluntary compliance measures to prevent fraud and abuse in government health programs, including Medicare and Medicaid. Adopting a voluntary compliance program is a lot like practicing preventive medicine; it helps identify and treat small problems before they become big problems, Inspector General June Gibbs Brown said.

Strong enforcement and strong voluntary prevention are equally important in safeguarding the government health programs from fraud and abuse, Brown said. And the cornerstone of our prevention efforts is the development of voluntary compliance guidance that, in partnership with the private sector, will help the healthcare community develop effective compliance programs.

The report, Compliance Program Guidance for Individual and Small Group Physician Practices, has been published in draft form, and after all the comments have been reviewed and incorporated. The OIG plans to publish a final version of the guidance later this year in the Federal Register.

According to the OIG, a great majority of physicians are honest and committed to providing high-quality medical care to Medicare beneficiaries. Under the law, physicians are not subject to civil or criminal penalties for innocent errors or even for negligence. The OIG acknowledges that the governments primary enforcement tool, the civil False Claims Act, only covers offenses that are committed with actual knowledge of the falsity of the claim, reckless disregard or deliberate ignorance of the truth, or falsity of a claim. The distinction between erroneous claims and fraudulent claims is one the OIG takes into consideration when investigating cases.

The Elements of an Effective Program

An effective compliance program can help physicians identify both erroneous and fraudulent claims and help ensure that submitted claims are true and accurate.
Similar to other guidance issued by OIG for clinical laboratories, hospitals, home health agencies, third-party medical billing companies, durable medical equipment suppliers, hospices, Medicare Plus Choice plans and nursing facilities, the draft of the physician guidance is based on the following seven elements:

implementation of written policies and standards of conduct,
designation of a compliance officer or contact,
development of training and education programs,
creation of open lines of communication to keep practice employees updated about compliance activities,
performance of internal audits to monitor compliance,
enforcement of standards through well-publicized disciplinary directives, and
prompt corrective action to detected offenses.

The draft guidance identifies specific compliance risk areas [...]