What is a Compliance Program?
Compliance Program Evaluation Guide
High Risk Compliance Areas
Model Compliance Programs

In an open letter to health care providers, the Office of Inspector General (OIG) states that "while compliance programs are not a novel idea, they are becoming increasingly popular as affirmative steps toward promoting a high level of ethical and lawful corporate conduct." If fraud is uncovered, the Department of Justice and the OIG will determine if "reasonable efforts have been made by management to avoid and detect any misbehavior that occurs within their operations."

The OIG indicates that there are seven fundamental elements of an effective provider compliance program.

· Implementing written policies, procedures, and standards of conduct
· Designating a compliance officer and compliance committee
· Conducting effective training and education
· Developing effective lines of communication
· Enforcing standards through well-publicized disciplinary guidelines
· Conducting internal monitoring and auditing
· Responding promptly to detected offenses and developing corrective action initiatives

Compliance Program Evaluation Guide

The following guide is designed to help you assess the effectiveness of your compliance program.

1. Does your compliance program include written policies and procedures establishing the necessary documentation for assigning a diagnosis code or procedure code to a claim?

2. Have you identified in writing clearly defined standards of legal and ethical conduct for all employees whose jobs impact government health care program reimbursements?

3. Do you have a designated compliance officer?

4. Do you have a hotline or other effective means of reporting compliance violations directly to the compliance officer?

5. Is there an education or training program in place which ensures that employees whose jobs impact government health care program reimbursements are aware of the compliance program and the ethical and legal standards for accurate claims submission, reporting and reimbursement?

6. Do employees receive continuing education on new laws, regulations, and billing procedures?

7. Is the staff interviewed periodically to ensure that they are aware of the compliance program?

8. Are there specific written disciplinary policies in place to deal with an employ that fails to comply with the ethical standards outlined in the compliance program?

9. Are there specific written policies for investigating and correcting problems that are identified through the compliance program?

10. Are there clear written policies that require that all employees' and prospective employees' identities be checked against a list of sanctioned individuals and that if they are sanctioned, services which they render cannot be billed to governmental health care programs?

11. Do you have clear and consistent written guidelines available to employees whose jobs impact government health care program reimbursements that indicate the appropriate retention requirements for records related to claims and governmental reports?

12. Are there clear and consistent written guidelines available to employees whose jobs impact government health care program reimbursements that ensure there is proper documentation to support all Medicare reimbursements?

Billing and Coding
· Billing for items or services not rendered
· Providing medically unnecessary services
· Upcoding
· Diagnostic related group (DRG) creep
· Unbundling
· 72 hour rule
· Duplicate billing
· Billing for transfer/discharge

Medicare Secondary Payer
· Failure to refund credit balances to Medicare and other federal programs
· Failure to accurately report all third party liability data

Patient's Rights
· Patient dumping
· Patient's freedom of choice
· Failure to provide covered services or necessary care to HMO members

Record Keeping and Documentation
· Services not authorized by a physician
· Forged physician's signature/orders
· False Cost Reports
· Record retention

Other
· Software licensing
· Improper hospice determinations of a person's life expectancy
· HHA claims for beneficiaries who are not homebound
· Hospital incentives that violate anti-kickback statutes
· Waiving of patient's co-insurance and deductible