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Compliance Program Development

Why a Compliance Program?

A compliance program will help providers in developing a “voluntary” compliance program that promotes adherence to statutes and regulations applicable to the Federal health care programs such as Medicare, Medicaid and Tricare.  The goal of voluntary compliance programs is to provide a tool to strengthen the efforts of health care providers to prevent and reduce improper conduct.

According to the OIG a well-designed compliance program can:  Speed and optimize proper payment of claims;

  • Minimize billing mistakes;Compliance Options
  • Reduce the chances that an audit will be conducted by HCFA or the OIG; and
  • Avoid conflicts with the self-referral and anti-kickback statutes.

Voluntary compliance programs also provide benefits by not only helping to prevent erroneous or fraudulent claims, but also by showing that the physician practice is making additional good faith efforts to submit claims appropriately. Physicians should view compliance programs as analogous to practicing preventive medicine for their practice. Practices that embrace the active application of compliance principles in their practice culture and put efforts towards compliance on a continued basis can help to prevent problems from occurring in the future.

A compliance program also sends an important message to a physician practice’s employees that while the practice recognizes that mistakes will occur, employees have an affirmative, ethical duty to come forward and report erroneous or fraudulent conduct, so that it may be corrected.

 Compliance Program Development

Effective Compliance Program Elements

This compliance program guidance for individual and small group physician practices contains seven components that provide a solid basis upon which a physician practice can create a voluntary compliance program:

  • Conducting internal monitoring and auditing;
  • Implementing compliance and practice standards;
  • Designating a compliance officer or contact;
  • Conducting appropriate training and education;
  • Responding appropriately to detected offenses and developing corrective action;
  • Developing open lines of communication; and
  • Enforcing disciplinary standards through well-publicized guidelines.

These components are similar to those contained in previous guidances issued by the OIG. However, unlike other guidances issued by OIG, this guidance for physicians and small practices does not suggest that such groups mplement all seven components of a full scale compliance program. Instead, the guidance emphasizes a step by step approach to follow in developing and implementing a voluntary compliance program.

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