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By Athena Mandros

We’ve all heard the stories – or been part of them. An organization owes thousands or hundreds of thousands of dollars back to the state or health plan for improper billing or documentation. Just few of the recent headlines illustrate the issue – Florida Medicaid Sanctions Four Behavior Analysis Provider Organizations and Over 400 Health Care Professionals Charged For Committing $1.3 Billion In Health Care Fraud, Including Opioid Distribution.

Sherry Marchand, CPMA, Principal, SMCPMA
Sherry Marchand, CPMA, Principal, SMCPMA

No executive team wants to be in position for large paybacks. And, that is why compliance programs—that minimize mistakes in billing and documentation—are extremely relevant. If they work, this type of ‘payback’ situation shouldn’t exist.

The question for executive teams – is your compliance program what you need to prevent paybacks? That was the was the focus of the session, Developing A Comprehensive Compliance Plan To Achieve Outstanding Audit Results featuring Sherry Marchand, CPMA, Principal, SMCPMA, and sponsored by TenEleven Group at The 2019 OPEN MINDS Technology & Informatics Institute. Ms. Marchand outlined the seven key elements of a robust compliance plan: implement written policies and procedures, designate a compliance officer and compliance committee, conduct effective education and training plan, develop effective lines of communication, conduct internal monitoring and auditing, enforce standards through disciplinary guidelines, and response promptly to detected offenses.

  1. Implement written policies and procedures – Every organization needs a written compliance plan that includes organizational policies, procedures, and a standard of conduct. The standard of conduct should put everyone at the organization “on notice” and clearly state that the organization does not tolerate fraud and abuse.
  2. Compliance officer and compliance committee – Regardless of size, every organization should have a compliance officer who is responsible for leading compliance related activities and a compliance committee. The organization can decide how often the committee meets, what the committee discusses, and how that information is disseminated.
  3. Conducting effective training and education – While a written plan is important, it is worthless if no one knows about it. At least one a year, but ideally more often, the compliance plan should be reviewed with staff and all new staff should learn about the plan as part of orientation. As issues are identified throughout the year, targeted training should be offered. All training should be documented in the compliance plan with the date, topic, presenter, and duration.
  4. Effective lines of communication – All organizations need to have a way for staff and consumers to communicate issues with compliance or other activities. At minimum, there should be a hotline to call. The hotline should feed back to the compliance officer and committee. Ms. Marchand recommended that if you are going to do one thing to improve compliance, start with the hotline. She explained that it is an easy fix.
  5. Conduct internal monitoring and auditing – At least monthly, organizations should conduct internal monitoring and auditing to review whether billed services were documented and properly coded. At least yearly, organizations should have an external audit based on a pre-decided report card. Additionally, the compliance committee should track trends related to payer recoupments to know what to monitor.
  6. Enforcing standards through disciplinary guidelines – The organization should have clear disciplinary standards for when there is non-compliance. These should be publicized across the organization, consistently enforced, and any disciplinary action taken should be documented.
  7. Responding promptly to detected offenses and undertaking action – When potential non-compliance issues are identified, they should be thoroughly and promptly investigated. If there is a violation, a corrective action plan should be put in place. Additionally, if necessary, the payer should be notified of overpayment and the proper law enforcement officer contacted if necessary.

Compliance plans are living documents and should not be reviewed once a year and placed on a shelf. Organizations should be actively monitoring their organization against the compliance plan and documenting action taken. Additionally, staff should also be actively educated on the plan throughout the year. Finally, there are software features that can help make compliance easier. Many of these features, which are a part of EHRs, can assist with clinical documentation and billing compliance.

For more on compliance programs, check out these resources in the OPEN MINDS Circle Library:

  1. Cybersecurity & The Threat Landscape
  2. Technology Moves From Compliance To Strategic – The Three Tech Mega Trends Of 2017
  3. Corporate Compliance Plans: Safeguarding Against Financial Loss & Reputation Ruin (Coffee Break Case Study)
  4. HIPAA Fines & HIPAA Audits On The Rise
  5. Parity Compliance Toolkit Applying Mental Health & Substance Use Disorder Parity Requirements To Medicaid & Children’s Health Insurance Programs
  6. 3 Ways To Improve Your Bottom Line – By Improving Your Collections
  7. Adapting Revenue Cycle Management For A VBR-Driven World
  8. Revenue Cycle Management: A New Model For A New Market
  9. Top Five Denials: Improve The Appeals Process & Focus On Denial Prevention
  10. The Coordination Of Benefits Issue: A Sticky Wicket For Some

For more, join us at The 2020 OPEN MINDS Performance Management Institute in Clearwater, Florida on February 13 for, “Rethinking Revenue Cycle Management: How To Optimize Operations For A Value-Driven World” with Vanessa R. Lane, MBA, Vice President, Revenue Cycle Management/ Data Analytics, Grafton Integrated Health Network.

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