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Slide 1: 10-STEP QUICK-START HEALTHCARE COMPLIANCE GUIDE Author: Thomas R. Rhudy, D.C., J.D., M.Div. http://www.CommunicationProfits.com/
Slide 2: 10-STEP QUICK-START HEALTHCARE COMPLIANCE GUIDE © 2008 All rights reserved. No part of this work may be reproduced in any form or by any means - graphic, electronic, or mechanical, including photocopying, recording, taping, or information storage and retrieval systems – without the express written permission of the publisher. Products that may be referred to in this document may be either trademarks and/or registered trademarks of the respective owners. The publisher and the author make no claim to these trademarks. While every precaution has been taken in the preparation of this document, the publisher and the author assume no responsibility for errors or omissions, or for damages resulting from the use of information contained in this document or from the use of programs and/or source code that may accompany it. In no event shall the publisher and the author be liable for any loss of profit or any other commercial damage caused or alleged to have been caused directly of indirectly by the use of this document. This document is sold with the understanding that neither the author nor the publisher is engaged in rendering legal or accounting services. Questions relevant to the specific legal and accounting needs of the purchaser should be addressed to practicing members of the respective professions. The author and the publisher specifically disclaim any liability, loss, or risk, personal or otherwise, incurred as a consequence, directly or indirectly, of the use and application of any of the techniques or contents of this product. Published: August 2008
Slide 3: 10-STEP QUICK-START HEALTHCARE COMPLIANCE GUIDE If you realize that you need a healthcare compliance program, but feel apprehensive about what seems to be such a daunting task, this Guide will assist you in gaining the confidence that you need to proceed step-by-step in creating a healthcare compliance program that will make you proud to be a healthcare provider once again. This Guide will show you the most important elements to consider in the development of a compliance program, irrespective of the size of your practice. It is dangerous to assume that because your practice is small (e.g., 1 doctor and 1-2 staff members), that you do not need to have such a program. Any healthcare practice can become the target of a fraud investigation! The following steps, if followed closely, will get you well on your way to a bona fide compliance program: Practice Analysis: First, and foremost, it will be necessary to assess the areas of your practice that pose the greatest liabilities. To determine this, you will need to consider the following: 1. Do you provide healthcare to patients who are either employees of the Federal Government who will be filing claims against/with their employers’ carrier, or who will be filing claims under a government contract (e.g., Medicare/ Medicaid)? 2. Do you accept Letters of Protection on 3rd-party liability claims? 3. Do you have high employee turnover? 4. Do you file your billing electronically? 5. Do you out-source your collections? 6. Do you contract with independent practitioners? 7. Do you contract with outside vendors? 8. Have any of your providers been sued for malpractice? 9. What percentage of your billings are denied/reduced? 10.Do you have a mechanism for responding to either denials or reductions in reimbursement? 11.Do you provide ongoing training to billing and collections employees regarding CPT coding and ICD-9 coding? 12.Do you perform background investigations on all employees prior to hire? 13.Do you provide a mechanism for reporting complaints for internal resolution? Once this assessment is competed, it will be necessary to develop policies and procedures to allow management of each potential liability. The Compliance Manual that we have created addresses those areas that pose the greatest liabilities for the largest number of providers. It is inadvisable to merely implement these policies prior to performing a thorough analysis of your individual practice needs. Delegation of Duties: It will be necessary to appoint a Compliance Officer who is qualified to oversee a healthcare compliance program. If you do not have an employee in your organization with such training, we have provided, and make available additional, resources that will prepare the appointed individual to assume such a role.
Slide 4: 1. Compliance Officer: The individual appointed must be someone who refuses to compromise the quality and integrity of the compliance program. Policies pertaining to billing, coding, documentation, etc. should be viewed as mandatory, not optional! 2. Compliance Committee: Once your Compliance Officer is appointed, it will be necessary to determine what departments within your practice should be represented on a Compliance Committee to which the Compliance Officer will report. Frequently, providers mistakenly conclude that the practice consists of only one department. Rarely would this be the case. Most practices will have, if nothing else, the following: (1) record keeping; (2) billing; (3) collections; and (4) production. Although one individual may wear hats for each department, it is best to consider these departments as discrete entities. This permits more effective management and analysis of your overall practice. Compliance Manual: The Compliance Manual we have prepared addresses areas of exposure to which attention must be directed to attenuate (i.e., lessen) the exposure arising in each area. This is one of the most critical areas of any compliance program, and should not be given short-shrift. Employee Manual: We have also provided an Employee Manual in which examples of employees’ duties and responsibilities are provided. It is recommended that the manual be tailored to the individual practice. While the duties and responsibilities included pertain to the principal areas of most healthcare practices, undoubtedly your practice has one or more unique areas that would benefit from slight modification of this manual. Vendor/Agent Contracts: We have also included sample contracts to be used when working with vendors, independent agents, and licensed providers who are not employees of your organization. Hotline: We have provided Hotline protocol, intended to provide a viable reporting mechanism for concerns/complaints concerning the organization’s practices. This protocol is effective in providing a reporting mechanism for concerns/complaints arising either internally (i.e., employees) or externally (e.g., patients, insurance adjusters et al.). Education: The policies/procedures contained in the manual serve as an excellent educational tool for all employees, agents et al. However, to be effective, as is true for all education, it is necessary for those policies and procedures to animate those with whom they are shared. Merely having a dormant document in which such policies/ procedures are contained will not accomplish your intended goal of developing a vibrant bona fide healthcare compliance program. Disciplinary Procedures: We have provided a guide to Disciplinary Procedures, applicable to both licensed and unlicensed employees. It is important to bifurcate these disciplinary procedures to ensure licensed providers that they are the individuals to whom boards of examiners will look for accountability, to whom law enforcement will look as the instigator of abusive and unnecessary procedures, and to whom governmental agencies will address inquiries into questionable/unusual practices. Unlicensed individuals must realize that their activities may also result in the accrual of personal criminal liability. Neither licensed nor unlicensed individuals are immune from prosecution. I was involved in one investigation in which a provider whose name was affixed to billing statements had been dead for more than six months, and the office manager’s sentence was actually longer than the doctors’.
Slide 5: Exit Interview: We have provided an Exit Interview form, as well as procedures to follow when employees sever their employment relationship, whether it be voluntary or otherwise. Failure to perform this procedure may result in many unnecessary claims (e.g., wrongful termination, “whistleblower” actions, etc.) and prove extremely costly. Training Sessions: Once the foregoing are completed, it will be necessary to set a time and place for the training session(s). It is important to conduct the training in a manner most likely to capture the largest number of employees/agents for which the training is intended. Any employees/agents who do not attend the plenary training session should be required to either attend a make-up training session or provide evidence of having obtained the information contained in the training session. Training Location: Ensure that the location of the training session is conducive to such training, and interruptions will be minimized. During one of our first compliance training sessions, the room in which we conducted the training was so hot that by the time we were finished, participants were practically stripped down to their underwear. Sound System: Ensure that you have an adequate sound-system. Too often, speakers conclude that they do not need a sound-system. Remember, sound-systems are for the listeners, not the speakers. It is also important to avoid having individuals attending the training session sit in areas that are “deadspots,” acoustically-speaking. Sign-In Sheets: Provide a sign-in sheet, identifying the date on which the training session is conducted, the employee’s/agent’s printed name, and the employee’s/agent’s signature. Pre-Test: Provide Pre-Test 1A to all employees/agents to determine the knowledge- base of the participants prior to the training. Videotaping Training Session: Training sessions should be memorialized, preferably via video. It is recommended that the taping, irrespective of the medium, be performed by a professional. If you do not know where to obtain such a professional, it is recommended that you contact a court-reporting service for recommendations. It is difficult to convince investigators that you take your compliance training seriously when an inattentive videographer allows the camera to focus on the back of someone’s head for ten minutes and the audio includes private discussions amongst audience members. Q&A: Conduct a Q&A session following the training. Remember the following: (a) have speakers repeat questions asked; (b) ask participants to rephrase ambiguous questions; and (c) refrain from addressing questions that are not relevant to the training session, stating that you will be happy to discuss the issue with the questioner at a convenient time following the training session. Post-Test: Provide Post-Test 1A to all employees/agents to determine the knowledge-base of participants following the training session. This will be a good metric to assess the effectiveness of the training session.
Slide 6: Please Note All rights reserved. No part of this work may be reproduced in any form or by any means - graphic, electronic, or mechanical, including photocopying, recording, taping, or information storage and retrieval systems - without the express written permission of the publisher. http://www.CommunicationProfits.com/