MEDICAL CLINIC COMPLIANCE OFFICERS: THEY SOLVE PROBLEMS YOU DIDN’T KNOW YOU HAD IN WAYS YOU DON’T UNDERSTAND
In 1960 health care costs comprised 5.3% of the Gross National Product (GNP). Today, health care costs comprise nearly 20% of GNP, almost double that of other nations. Health care has also become a priority for government regulators.
Over the last 30 years, an alphabet soup of standards, statutes, and regulations have been adopted to address the health care costs and the potential for health care waste and abuse. These include the Anti-Kickback laws (AKS), state and federal False Claims Acts (FCA), the Stark Amendments, HIPAA, the HITECH Act, and the Patient Safety and Quality Improvement Act (PSQIA).
A multitude of government agencies enforce these laws. They include the Centers for Medicare & Medicaid Services (CMS), the U.S. Department of Health and Human Services (DHHS), the Minnesota Attorney General’s Office, the United States Department of Justice, and the Minnesota Departments of Health and Human Services, among others.
The Office of Inspector General of DHHS (OIG) expects health care clinics and organizations to create a compliance program to reduce the potential for waste and abuse. A compliance program is not one size fits all. What is appropriate for a small physician office differs from what is suitable for a large clinic. Either way, a compliance program is a necessity that helps protect health care clinics and organizations from rogue employees and regulatory infractions. In grey areas where mistakes can lead to hefty government penalties or even criminal allegations, a compliance program can help convince regulators that the clinic is operating in good faith and doing its best to achieve regulatory compliance.
The OIG, CMS and U.S. Department of Justice have identified several core elements of an effective compliance program. Key elements include:
Compliance Program. The organization should adopt and distribute a Code of Conduct that is brief, easily readable and covers general principles. The organization’s more thorough policies, procedures and standards should be contained in a written compliance manual that is available to staff. The manual should address expectations for staff, but also for certain vendors, suppliers, and contractors. The compliance program should be scaled to the size and complexity of the organization. The compliance documents of a three-person doctor’s office will look a lot different than that of a sprawling health care system.
Compliance Officer. The organization should appoint a person to serve as a compliance officer. In small organizations, that person may have multiple roles. In larger organizations, compliance is a full-time job. Organizations of sufficient scale should also create a compliance committee to support the compliance officer. These individuals should be given adequate resources, authority, and access to do their jobs, including access to patient and billing records, third party contracts, and other documents that relate to regulatory matters.
Training and Education. The compliance officer should conduct training and education of the staff. The Federal Sentencing Guidelines expect a clinic to take reasonable steps to communicate periodically and in a practical manner the organization’s standards and procedures, and other aspects of the compliance and ethics program. This is done by conducting effective training programs and otherwise disseminating information appropriate to staff members’ respective roles and responsibilities.
Compliance Monitoring. The compliance officer should monitor and audit the clinic for compliance and help set up systems for staff and departments to monitor their own work. This can include informal daily spot-checks or monitoring of claims submissions for accuracy to more formal periodic audits of claims submissions.
Open Communication. An expectation should be set that employees have a duty to report suspected violations of law or compliance policies. This protects the clinic from everything from innocent mistakes to malicious conduct by staff. The compliance program should establish effective lines of communication so that clinic employees are comfortable voicing compliance concerns. Nonretaliation is fundamental to a compliance program. An employee “hotline” is an example of such a communication.
Enforcement. The compliance officer should enforce disciplinary guidelines. Compliance should work with human resources and legal teams to ensure that the standards and consequences for violations are consistently enforced.
Prompt Action. The compliance officer should promptly undertake corrective and remedial action if there is a lapse. Failure to ensure timely and effective remedial action for offenses can create additional exposure for the organization.
Physician groups and other health care organizations face difficult regulatory and compliance issues. A good compliance plan can help an organization nurture a culture of compliance and get in front of potential compliance shortcomings.
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The law firm of Swanson Hatch, P.A. represents health care providers in complex legal, regulatory, compliance, and professional licensing matters and helps health care organizations establish regulatory compliance programs. Former Minnesota Attorneys General Lori Swanson and Mike Hatch were active participants in health care matters during their respective tenures as attorneys general. They supervised the office’s Medicaid Fraud Control Unit, which enforces state Medical Assistance laws and undertakes actions against medical providers that overbill Medical Assistance. They also provided legal representation to the Minnesota Board of Medical Practice and the Minnesota Departments of Human Services, Health, and Commerce. Prior to her twelve years as Minnesota Attorney General, Lori Swanson previously served as Solicitor General and Deputy Attorney General of the State of Minnesota. Swanson is a member of the American Health Law Association and was named by Health Leaders magazine as one of 20 American making a difference in health care. Before he became Attorney General, Mike Hatch previously served as Commissioner of the Minnesota Department of Commerce for eight years, where he regulated the insurance industry. Lori Swanson can be reached at lswanson@swansonhatch.com, or at 612-315-3037. Mike Hatch can be reached at mhatch@swansonhatch.com, or at 612-315-3037. The firm’s website is www.swansonhatch.com .
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www.swansonhatch.com
431 S Seventh Street, Suite 2545
Minneapolis, MN 55415 612-315-3037
The materials in this article are for informational purposes and do not constitute legal advice, nor does your unsolicited transmission of information to us create a lawyer-client relationship. Sending us an email will not make you a client of our firm. Until we have agreed to represent you, nothing you send us will be confidential or privileged. Readers should not act on information contained in this article without seeking professional counsel. The best way for you to inquire about possible representation is to contact an attorney of the firm. Actual results depend on the specific factual and legal circumstances of each client’s case. Past results do not guarantee future results in any matter.
THEY SOLVE PROBLEMS YOU DIDN’T KNOW YOU HAD IN WAYS YOU DON’T UNDERSTAND
In 1960 health care costs comprised 5.3% of the Gross National Product (GNP). Today, health care costs comprise nearly 20% of GNP, almost double that of other nations. Health care has also become a priority for government regulators.
Over the last 30 years, an alphabet soup of standards, statutes, and regulations have been adopted to address the health care costs and the potential for health care waste and abuse. These include the Anti-Kickback laws (AKS), state and federal False Claims Acts (FCA), the Stark Amendments, HIPAA, the HITECH Act, and the Patient Safety and Quality Improvement Act (PSQIA).
A multitude of government agencies enforce these laws. They include the Centers for Medicare & Medicaid Services (CMS), the U.S. Department of Health and Human Services (DHHS), the Minnesota Attorney General’s Office, the United States Department of Justice, and the Minnesota Departments of Health and Human Services, among others.
The Office of Inspector General of DHHS (OIG) expects health care clinics and organizations to create a compliance program to reduce the potential for waste and abuse. A compliance program is not one size fits all. What is appropriate for a small physician office differs from what is suitable for a large clinic. Either way, a compliance program is a necessity that helps protect health care clinics and organizations from rogue employees and regulatory infractions. In grey areas where mistakes can lead to hefty government penalties or even criminal allegations, a compliance program can help convince regulators that the clinic is operating in good faith and doing its best to achieve regulatory compliance.
The OIG, CMS and U.S. Department of Justice have identified several core elements of an effective compliance program. Key elements include:
Physician groups and other health care organizations face difficult regulatory and compliance issues. A good compliance plan can help an organization nurture a culture of compliance and get in front of potential compliance shortcomings.
www.swansonhatch.com
431 S Seventh Street, Suite 2545
Minneapolis, MN 55415
612-315-3037
The materials in this article are for informational purposes and do not constitute legal advice, nor does your unsolicited transmission of information to us create a lawyer-client relationship. Sending us an email will not make you a client of our firm. Until we have agreed to represent you, nothing you send us will be confidential or privileged. Readers should not act on information contained in this article without seeking professional counsel. The best way for you to inquire about possible representation is to contact an attorney of the firm. Actual results depend on the specific factual and legal circumstances of each client’s case. Past results do not guarantee future results in any matter.
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Swanson | Hatch, P.A.
431 S. 7th Street, Suite #2545
Minneapolis, MN 55415
612-315-3037
www.swansonhatch.com