Compliance for Your Organization
Has your organization considered an anesthesia compliance plan to meet the requirements of the Office of Inspector General (OIG)? Have you recently updated your policies and procedures? Have you trained your staff on the latest federal regulations that might affect your billing for anesthesia? We have a solution for your anesthesia company.
Having a compliance plan is important for many reasons but the most important is that it is mandated by the Affordable Care Act (ACA) and recommended by the Office of Inspector General (OIG). In addition, the United States Sentencing Guidelines lists a compliance plan as one of the factors that should be considered by the Department of Justice (DOJ) during an investigation or determination of prosecution, resolution or form of penalty. A well-designed plan is the best way of preventing billing errors and potential claims of fraud, waste or abuse. It can also help you in the case of a review or audit by a federal or state program and prevent or lessen legal expenses, fines or penalties.
The Office of Inspector General (OIG) has given clear direction in the publication “Compliance Program Guidance for Individual and Small Group Physician Practices” on establishing a voluntary compliance plan. The intent of this initiative was to assist in preventing submission of erroneous claims or engaging in unlawful conduct involving the federal health care programs. By developing these compliance plans health care providers can use internal controls to better monitor the adherence to applicable statutes, regulations and program requirements.
Why Compliance is Important
Having a compliance plan is important for many reasons but the most important is that it is required by law. It is the best way of preventing erroneous billing and fraudulent claims. It will also help you in the case of a potential audit and help prevent enormous legal expenses. The Federal Sentencing Guidelines explicitly reward the adoption of an “effective” compliance program by reducing the imposed sanctions. For years the Office of Inspector General (OIG) has encouraged providers to implement compliance programs. They have also indicated providers who lack programs risk more severe sanctions if penalties are given.
The National Health Care Anti-Fraud Association reports that financial losses due to fraud can be as much as ten billion dollars. The U.S. HHS and OIG recovered $5.9 billion related to healthcare fraud in 2019.
It is important for all healthcare organizations to understand the laws and regulations and comply with them and to follow any associated guidelines. Failing to prepare a compliance plan and compliance training for your organization can result in significant problems in the face of an OIG or DOJ complaint and investigation.
Since 1976, the Department of Health and Human Services Office of inspector General (HHS-OIG) has been working to prevent fraud, waste and abuse in federally funded healthcare programs. These include Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). HHS- OIG’s focus is to protect the integrity of HHS programs as well as the health and welfare of program beneficiaries.
Compliance is Mandatory
Initially HHS-OIG published voluntary compliance guidance for individual and small group healthcare practices. Once the Patient Protection and Affordable Care Act (ACA) went into effect in 2010 compliance programs became mandatory. Section 6401 of the ACA stipulated that healthcare providers must establish compliance programs as a condition of participation in Medicare, Medicaid and/or the Children’s Health Insurance Program (CHIP).
Insurance companies today require or recommend that medical providers develop a compliance program for the protection of the organization.
The Affordable Care Act (ACA) has mandated physicians and group practices to establish compliance programs if they want to provide services under Medicare, Medicaid and Children’s Health Insurance Program.
Commercial insurers are also requiring medical providers to create a compliance plan as a condition of participation in their program. Those who do not create a plan are at risk of not being allowed to participate in the healthcare program.
CMS insists that medical providers will be able to protect themselves from improper conduct if they create a compliance program. A functional program ensures that government rules are enforced and that they provide quality care. A good compliance program will help prevent criminal behavior, protect against fraud, improper payments, abuse of the system and other liabilities.
ACA Compliance Core Elements
The ACA recommends that healthcare providers implement a compliance plan, if they haven’t yet, that includes the seven core elements as a foundation for their program.
- Establish and adopt written policies and procedures to promote the provider’s commitment to compliance. Include sanction screenings as part of the healthcare compliance plan. Ensure that there’s a routine process in place to monitor potential compliance issues.
- Identify and appoint an individual to serve as the compliance officer and charge this person with the responsibility for monitoring compliance efforts and enforcing practicing standards.
- Establish reporting systems whereby individuals can report complaints about compliance items without fear of retaliation. Some providers have found it to be helpful to set up an anonymous hotline number.
- Make a commitment to offering formal education and training programs at all levels of employment. Make it part of the employee orientation process.
- Continually audit and monitor systems to ensure that they’re effective and to head off potential problems.
- Develop policies to enforce the standards of conduct and establish disciplinary measures for employees who don’t comply with the requirements.
- Take corrective action when vulnerabilities are identified.
Anesthesia Compliance Consultants (ACC) will assist your organization with the creation of a compliance plan that covers the seven components. Our team of experienced professionals, crafts compliance plans consistent with regulatory, medical, billing and coding standards. Our professionals have been involved in the business of anesthesia compliance since 2002 and have the experience both legal and as anesthesia providers to fully comprehend the needs of anesthesia practices.
HIPAA Privacy Compliance Plans
The Privacy Rule established standards for the protection of health information. The US Department of Health and Human Services (HHS) issued the Privacy Rule to implement the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Privacy Rule establishes standards for individuals’ privacy rights to help them control the use of their health information. One of the goals of the Privacy Rule is to assure proper protection of individuals’ health information while allowing the necessary flow of health information to provide and promote health care and to safeguard health and well-being.
Anesthesia Compliance Consultants (ACC) have been in the business of HIPAA consulting since the Privacy Rule went into effect. We have assisted many large organizations in developing their HIPAA Privacy programs. Our professionals are prepared to assist you with all these important policies and procedures. ACC develops and consults on HIPAA compliance plans that include HIPAA privacy and security, policies and procedures and breach reporting requirements in compliance with the HIPAA Rules. Of great importance, ACC is always available to assist you when questions arise regarding the HIPAA Rule. We would be happy to discuss with you how we can help with your program.
Compliance and HIPAA Training
A critical part of any effective compliance program is appropriate training and education. A company must ensure that policies and procedures are integrated and made active through initial and periodic training of employees, contractors, and other stakeholders. We are prepared to help train your staff in all important aspects of compliance and privacy to protect your organization from violation of federal guidelines. We have a variety of courses that are available to meet these needs.