LAS VEGAS Proper documentation is key to an effective corporate compliance program and can serve as evidence of a good-faith program to investigators, one compliance expert said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.
Documentation should include the group's compliance policies and procedures, training, and any compliance issues and the resolution, said Edward R. Gaines III, senior vice president for compliance and general counsel for Healthcare Business Resources Inc. of Durham, N.C.
The Health and Human Services Department's Office of Inspector General outlines seven elements of an effective corporate compliance program:
▸ Compliance standards and policies.
▸ Oversight.
▸ Education and training.
▸ Effective lines of communication.
▸ Monitoring and auditing.
▸ Enforcement and discipline.
▸ Response and prevention.
Another important element of a compliance program is the ability to prevent and detect fraud and abuse, Mr. Gaines said. Implementing a corporate compliance program will mitigate the risk of potential liability.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) expanded the federal False Claims Act to all payers, including commercial claims. And the government does not need proof of intent to take action. Physicians are liable for knowingly allowing or encouraging false claim submission, being deliberately ignorant, or having a reckless disregard for the truth, according to the HIPAA law.
In addition, even if the physician is not responsible for performing the billing and coding, they are liable if the claim is submitted in their name.
Mr. Gaines advised physicians to start at the top by getting a commitment to the compliance program from senior-level executives in the organization. "One of the [places] where compliance programs frequently fail is that they don't have clear leadership from the top," he said.
Create an environment where physicians and staff members are free to question without fear of retribution or retaliation, he added.
Medicare contractors and other auditors will use data analysis to detect aberrant billing practices. The auditors tend to rely on billing reports that compare providers of the same specialty in an area. The auditor might also look at increases in critical care utilization versus historical trends for the group, for example.
But physicians groups can be prepared, Mr. Gaines said, by considering why their E/M coding and billing data might be different from CMS national or Medicare carrier data.