Custom fit is best design for your compliance plan
Custom fit is best design for your compliance plan
All employees should know, understand your plan
You've probably taken a good look at the Office of Inspector General's (OIG) Compliance Program Guidance for Hospitals since it was published in the Federal Register in February. And if you've delved deeply into the 45-page document, it's likely to have raised quite a few questions regarding how the OIG expects your particular organization to adhere to their guidelines.
Some helpful clarifications were offered recently by Sue Prophet, RRA, CCS, director of classification and coding for the American Health Information Management Association (AHIMA). She spoke at a March joint conference of AHIMA, its ambulatory care and quality management specialty groups, and the Society for Clinical Coding, an affiliated organization.
One important piece of advice: Don't just download the OIG model plan, print it, punch three holes in it, and consider it your hospital compliance plan.
"That's why they didn't call it a plan, but guidance," Prophet said. There is no single "best compliance plan" given the diversity of the health care industry, she added.
On the other hand, it isn't necessary that your organization adhere to every point in the plan down to the smallest detail. The OIG plan can be modified to fit your particular organization. For smaller organizations, some of the suggested compliance initiatives are simply not feasible. A hotline, for example, in a six-employee physician's office just wouldn't be practical, Prophet said. With such a small staff, "Who's going to man the hotline?" she asked. A suggestion box would serve the same purpose in a very small organization as an elaborate hotline system in a large health care system.
You don't have to follow the OIG plan to the letter, but be assured, you do have to have a compliance plan in place, Prophet warned. "With all these fraud investigations, there is such a multitude of reasons that an organization could be picked for an investigation. It's a way of demonstrating that you are taking measures to make sure that staff and contractors . . . are all complying with appropriate rules and regulations."
Are off-the-shelf plans acceptable?
What about buying a compliance plan from a company selling off-the-shelf products? "The OIG really frowns on that," Prophet said. Such a plan would not be considered very effective since it wasn't designed with your particular organization in mind - a loose fit at best that might not work well.
"Having a program that doesn't work is considered by the OIG worse than having no program at all," she said. "If violations are found, penalties would be higher "than in an organization that had no plan at all. From the OIG's perspective, an unworkable, off-the-shelf plan "shows you really don't understand compliance at all," she added.
But having an effective compliance plan that is known about and used by employees at every level of the organization is solid ground to stand on if allegations of fraud or abuse are leveled at your organization. The OIG "will look at a compliance program as a mitigating factor - but it has to be an effective one," Prophet said.
In the course of an investigation, investigators will likely interview employees at all levels to determine how well the plan has been communicated and whether it's really used or just "window dressing," Prophet said. They could ask such questions as:
· Have you seen the compliance plan?
· How well do you know its contents?
· Do you have a compliance hotline?
· What is the hotline phone number?
· Have you ever called the hotline? Would you feel comfortable calling it?
Not just for Medicare
Prophet offered the following tips for designing and implementing an effective compliance plan:
· The plan should cover policies and procedures for all payers, not just Medicare.
· It should be written in language that is clear and easily understood - even by employees with low levels of reading comprehension.
· The plan should be translated into foreign languages if warranted by staff members whose reading comprehension in English is low.
· It should require background checks of all candidates for jobs that include the ability to submit claims. This is considered a high-risk job category and includes coders and billers.
· Background checks should include references as well.
· The plan should require that new information be disseminated on a regular basis.
For example, simply saying that your HIM department never received a particular bulletin that was mailed to the business office is not considered a valid excuse but an internal communications problem.
· It should include provisions for employees to report suspicions of fraud and abuse.
In more than 90% of whistle-blower lawsuits, employees bringing suit first tried to resolve the problem internally but sought help outside the organization when their concerns were ignored.
· Organizations should use interactive methods to train and educate staff on new rules and regulations.
Problem-solving scenarios during inservice sessions, for example, will avoid passive learning and bring the point home.
· Adherence to the compliance plan should be a factor in employee evaluations.
· Managers and supervisors should be held responsible not only for their own adherence to the compliance plan but for the adherence of their staff. Their evaluations should be written accordingly.
· Records of compliance monitoring, audits, and hotline reports should be kept for six years.
· Employees shouldn't be reprimanded for using the compliance hotline to report noncompliance problems.
That creates the impression that the hotline is not accessible. Instead, listen to all hotline reports, then refer noncompliance issues to the appropriate departments and deal with such issues promptly.
There is still some debate on when it is appropriate to report an overpayment to the government and when it is sufficient simply to return the overpayment to the fiscal intermediary, Prophet said. A good rule of thumb is to report a pattern of overpayment or a large sum to government officials. When ongoing auditing reveals an isolated occurrence or a small overpayment, it may be appropriate simply to work through the fiscal intermediary. "[But] the jury is still out on what you should self-report and what you should handle," Prophet said.
Looking ahead, it is clear from the OIG 1998 Work Plan that compliance will continue to be an issue at the forefront of government oversight. The Work Plan will focus on the following areas:
· DRG coding;
· PATH;
· physician visit coding;
· physician use of diagnosis codes;
· National Correct Coding Initiative;
· laboratory services;
· billing service companies;
· pneumonia DRG upcoding;
· observation stays;
· transfers;
· revenue codes billed by skilled nursing facilities;
· physicians with excessive nursing home visits.
The good news for HIM professionals, Prophet said, is that your training in documentation and coding will prove extremely useful as compliance weaves itself into the fabric of health care delivery. "Our background is invaluable to the whole compliance issue. Our cornerstone - documentation - is the key to all of this."
(Editor's note: Health information management professionals have long looked for a way to mine the rich potential of medical records, an efficient way to search, index, and organize the information with the ultimate goal of improving the quality of care. But the incompatibility of platforms and programs across myriad computer systems has been a brick wall - until now. A new system for standardizing documentation - including medical records - has just gained approval as an international standard. The possibilities it offers for mining health data promise to revolutionize health information management and administration.)
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