Draft compliance plan: Coders, billers find themselves in the spotlight
Staff education, training are cornerstones
Although there is no official word on when the finished plan will be published, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) has circulated a draft of its long-awaited Model Compliance Plan for Hospitals to leaders in the health care industry.
Heralded as part of its much-publicized crackdown on fraud and abuse in the sprawling federal Medicare and Medicaid systems, the draft hospital compliance plan follows on the heels of the Model Compliance Plan for Clinical Laboratories, published this past spring. (See Hospital Payment & Information Management June 1997, pp. 83-84.)
Like its lab counterpart, the hospital plan emphasizes the need not only to create a compliance plan but to implement it throughout every level of personnel.
A final version of the hospital compliance plan was slated to be published in the fall. Carolyn Lundberg, JD, an attorney in the Office of the Counsel to the Inspector General, says it’s unlikely it will be published before January because various "partners" in the effort, including leading health care organizations such as the American Hospital Association, are reviewing the draft and submitting their comments.
The American Health Information Management Association (AHIMA) also has contributed to developing the plan but will not comment until a final version is published, a spokesman says.
Although the final version will likely contain some changes, the draft advises that hospital compliance plans comprise several key elements, according to a report by the Washington, DC-based law firm Reed Smith Shaw & McClay, whose attorneys have seen a copy. The key elements of a hospital compliance plan should contain the following:
Establish compliance standards, procedures, and policies.
Standards of conduct should be tailored specifically to each part of the organization’s operations and to every level of personnel. "Physician professional services, in particular, must be properly documented especially with regard to DRG coding, individual Medicare Part B claims, patient discharge, and continuing education requirements," according to Reed Smith. "Late entries and marginal notes must be explained. Billing must be accurate and bills should be submitted only when appropriate documentation is available for audit and review. Standards should take into account the regulatory exposure for each hospital department." (See box, at right, for details of areas of specific concern.)
Assign oversight responsibility to an individual high in the organization’s structure.
A compliance officer if you don’t already have one in place should be a senior hospital official with direct access to the Board of Directors and the CEO, Reed Smith says. He or she should be free to investigate as needed and should be part of management and not subordinate to the General Counsel or Comptroller’s Office. Health care systems with more than one hospital should have a central compliance officer as well as counterparts in each individual hospital.
The draft also recommends creating a compliance committee, according to Reed Smith.
Conduct extensive training and education programs.
"The OIG particularly recommends targeted training for employees and managers who can create legal exposure to enforcement actions in areas such as billing and coding," Reed Smith says. Since these departments frequently experience high turnover, continual training on fraud and abuse laws, billing, coding, and ethical marketing techniques and management styles is critical. Special emphasis should be placed on DRG 72-hour rules, lab unbundling, teaching physician supervision, billing, upcoding, Stark I and II, anti-dumping laws, documentation on medical records, admissions, transfer and discharge policies, and documentation guidelines.
"Education and training of new and existing personnel at all levels is critical, and corporate ethics must be part of the training. Participation in training programs should be mandatory to ensure that employees know the organization’s standards of conduct, and procedures should be established for alerting senior management to problems," the report states. Failure to attend training should result in disciplinary action and possible termination. Further, employees should be required to acquire a minimum number of training hours as a condition of employment and records should track and certify their training. (See story, above, for elements of basic training for all employees.)
Monitor and audit to detect noncompliance and improve quality.
The draft says that thorough monitoring and regular reporting to senior hospital staff are advised. Regular periodic audits by internal and/or external auditors or health care experts should be performed at least annually, according to Reed Smith. "At a minimum, audits should focus on laws governing kickbacks, referrals, and coding," it says. The OIG emphasizes that overpayments should be returned immediately to the affected payer.
Develop effective lines of communications for reporting violations and clarifying policies.
The compliance plan should initiate an open-door, anonymous, nonretributive policy for all employees to encourage open communication and reporting of potential fraud, according to Reed Smith. The compliance officer should keep a log of these reports and forward the information to the CEO and compliance committee as part of a consistently applied documentation process.
Enforce standards through well-publicized discipline guidelines and procedures.
Spell out penalties for noncompliance
A compliance plan should contain a written policy that details disciplinary action for failing to comply with hospital policies. Violations should lead to "significant sanctions, including termination, where appropriate," according to Reed Smith. And senior managers, supervisors, medical staff, and administrators are seen as accountable for not only failing to comply themselves but for the failures of their subordinates. Managers are at least indirectly aware of many fraudulent schemes, in the OIG’s view, Reed Smith says.
Respond immediately to detected offenses and prevent further violations through systemic changes and corrective actions.
Immediate steps should be taken to stop violations when they are discovered, the plan says. Potential violations should be investigated promptly by the compliance officer, who should report the findings to the OIG and/or return overpayments if necessary. That report should be made to the OIG within 30 days of finding credible evidence of misconduct which violates either criminal, civil, or administrative laws. The model lab compliance plan allows 60 days to report evidence of criminal or material civil violations.
"The OIG reiterates that failure to promptly repay any overpayments could be interpreted as an intentional attempt to hide the overpayment from the Government and increase the hospital’s potential exposure," Reed Smith states.
In addition, the plan says all employees should have a background and reference check, and hospitals should consider prohibiting employing people who have been convicted of a criminal offense related to health care or who are listed as debarred, excluded, or otherwise ineligible for participation in federally funded health care programs, according to Reed Smith.
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