7 Components Guiding Prevention, Detection and Effective Compliance

Posted by Digital Manager on Tue, Apr 14, 2015 @ 08:30 AM

Showing a Sincere, Ongoing Effort to Comply Is a Sound Investment.  

As far back as 2000, The Department of Health and Human Services Office of Inspector General (OIG) has published voluntary compliance program guidance for individual and small group physician practices recommending that 7 key components be addressed to prevent the submission of erroneous claims or unlawful conduct involving the Federal health care programs. Have you put all 7 into action? 


The benefits of a well-designed and executed compliance program are numerous. Preventing violations from occurring and monitoring adherence to regulations can actually work to:      

  1. Reduce billing mistakes;
  2. Speed and optimize proper payment of claims;
  3. Reduce the chances that an audit will be conducted by OIG or The Centers for Medicare & Medicaid Services (CMS) or other health plans across the country;
  4. Avoid the potential for fraud, waste and abuse

The 7 Components Pay Dividends Beyond Preventing Violations and Take Backs    

Make sure you’re aware of the seven core components of an effective compliance program and take proactive steps to incorporate each of them in a manner that best suits your practice.

1. Written Policies, Procedures and Standards of Conduct

Creating a baseline of compliance policies and procedures is essential because it promotes consistency and uniformity in how your practice operates. Written policies should clearly describe expectations of compliance in detail by outlining procedures, standards and the organization’s commitment to support ethical conduct in line with all applicable laws and regulations.     

2. Designation of a Compliance Officer/Contact(s) and Compliance Committee

Establishing reasonable oversight of your compliance program begins with designating a compliance officer and/or compliance contact(s)/committee responsible for program. Whether an internal employee or outsourced role, the designee has responsibility for the day-to-day operations of the program, monitoring and reporting on the status of compliance activities. When issues arise, employees should know how to contact your designated compliance officials.   

3. Conducting Appropriate Training and Education

Each practice should ensure all workforce members receive initial training before they begin their assigned duties and recurrent education for Coding and Billing compliance, OSHA and HIPAA regulations on an annual basis or as appropriate.

4. Auditing and Monitoring

Practices should see that they have sufficient resources and support to measure the effectiveness of their compliance program. Through auditing and monitoring, compliance risks can be identified and addressed. Practices do well to focus on auditing E/M services as they pose the highest risk of exposure to outside audit. With routine Evaluation & Management (E&M) medical chart reviews and claim submission audits, you gain confidence that you are complying with applicable coding, billing and documentation requirements.

5. Responding to Detected Offenses and Developing Corrective Action Measures

When potential offenses are detected, suspect activity or conduct must be thoroughly investigated to determine if there is a genuine violation. Where there is credible evidence that the misconduct may violate criminal, civil or administrative law, prompt referral or disclosure to an appropriate Government authority or law enforcement agency is called for.  Actions taken to mitigate future incidents should be thoroughly documented and communicated.

6. Developing Open Lines of Communication

Every employee has a duty to report any real or suspected violations of laws, regulations, policies and/or questionable conduct to the appropriate supervisors or the compliance officer. The practice needs to ensure open communication as well as the opportunity for anonymity, for employees who report violations or questionable conduct without fear of retaliation or loss of employment.

7. Enforcing Disciplinary Standards through Well-Publicized Guidelines

A compliance plan cannot be a shelf item with policies and procedures that are not actionable. Written policies that outline appropriate disciplinary sanctions on those who fail to comply must be widely publicized and reviewed at least annually with the staff.

A World of Compliance Resources at Your Fingertips

Contact us today to learn about solutions that can help you create effective policies, teach and reinforce the right behaviors to protect your brand and help you stay in compliance.  

Watch a Free Webinar with more on  “7 Key Elements” right now

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Topics: Regulatory Compliance, Coding

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