What can you do to reduce your chance of becoming a target of a fraud investigation, or if you do become a target, minimize the risk of assessment of maximum penalties? How can you assure and demonstrate that your organization has accurate medical record documentation that supports the diagnoses and services reported on the claim for reimbursement, and ethical coding practices?
Corporate compliance programs are seen as an effective mechanism to assure compliance with regulations and minimize risk of fraud. At a minimum, comprehensive compliance programs should include the following seven elements. These seven elements were the ones the OIG identified as being most problematic re: increased potential for fraud & abuse within an organization.
(1) The development and distribution of written standards of conduct (which means they should be incorporated into your orientation process for all employees), as well as written policies and procedures that promote the home health agency’s commitment to compliance (e.g., by including adherence to the compliance program as an element in evaluating managers and employees) and address specific areas of potential fraud, such as claims development and submission processes, cost reporting, and financial relationships with physicians and other health care professionals and entities;
(2) The designation of a compliance officer (How many of you have a designated compliance officer?) and other appropriate bodies, e.g., a corporate compliance committee (Do any of you have a compliance committee charged with the responsibility for operating and monitoring the compliance program, and who reports directly to the CEO and the governing body)
(3) The development and implementation of regular, effective education and training programs for all affected employees (How many of you address compliance at least annually w/all staff?);
(4) The creation and maintenance of a process, such as a hotline (Does anyone here have a hotline?) or other reporting system, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation;
(5) The development of a system to respond to allegations of improper/ illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations, or Federal health care program requirements;
(6) The use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas;
(7) The investigation and remediation of identified systemic problems and the development of policies addressing the non-employment or retention of sanctioned individuals.
References
- Report on the Financial Statement Audit of the Health Care Financing Administration for Fiscal Year 1996.
- Department of Health and Human Services. 1998 Office of Inspector General workplan.
- Prophet, Sue. “Coding Compliance: Practical Strategies for Success.” Journal of AHIMA 69, no.1 (1998): 50-61
