Medical Billing is a complex industry and the government is aggressively using audits and investigations as a tool to recover money from the healthcare industry.
We have seen many instances where the government has used minor administrative rule violations to try to prevent payment, even when the healthcare service was delivered.
Medicare laws, regulations and guidance change so frequently that many practices are making incorrect assumptions based on historical information, which is no longer valid. Most healthcare organizations state they have some type of compliance program, which is supposed to account for these updates and changes, though is this program being regularly maintained and updated?
Our strengths lay in focusing on:
- The specific regulation for compliance.
- Doing what must be done in order to comply.
- Tailoring the compliance programs to the practice or facility.
- Pursuing the compliance with a “good faith effort”.
The best defense is to establish evidence that demonstrates your efforts to seek out and correct billing errors. If you have a comprehensive program to prevent errors and to refund money when errors do occur, that supports the argument that any error you fail to detect is inadvertent.
Take a look at your compliance program – Is the program an organization-wide plan to avoid and, if necessary, investigate allegations of wrong doing?
Most compliance plans are developed according to the Federal Sentencing Guidelines who have established these seven elements that constitute an “effective” compliance program.
- Standards and procedures designed to ensure compliance with all laws
- Oversight of procedures by a high level person (typically someone with the title of Compliance Officer)
- Care taken to avoid giving responsibility to individuals who have a “propensity to engage in illegal activities”
- Training
- “Reasonable steps” to achieve compliance with standards (i.e., monitoring and reviewing compliance)
- Consistent enforcement of policies and procedures, including discipline when necessary
- Appropriate response to all detected violations, including action to prevent further similar offenses
