The following is an excerpt from the Human & Health Services – Guidelines for 3rd Part Medical Billing Companies
- Program Guidance for Third Party Medical Billing Companies
- 1. Introduction
- A. Benefits of a Compliance Program
- B. Application of Compliance Program Guidance
- II. Compliance Program Elements
- A. Written Policies and Procedures – Part I | Part II
- B. Designation of a Compliance Officer and a Compliance Committee
- C. Conducting Effective Training and Education
- D. Developing Effective Lines of Communication
- E. Enforcing Standards Through Well-Publicized Disciplinary Guidelines
- F. Auditing and Monitoring
- G. Responding to Detected Offenses and Developing Corrective Action Initiatives
- III. Conclusion
B. Designation of a Compliance Officer and a Compliance Committee
1. Compliance Officer
Every billing company should designate a compliance officer to serve as the focal point for compliance activities. This responsibility may be the individual’s sole duty or added to other management responsibilities, depending upon the size and resources of the billing company and the complexity of the task. For those billing companies that have limited resources, the compliance function could be outsourced to an expert in compliance.57
Designating a compliance officer with the appropriate authority is critical to the success of the program, necessitating the appointment of a high-level official in the billing company with direct access to the company’s governing body, the CEO, all other senior management and legal counsel.58 The officer should have sufficient funding and staff to perform his or her responsibilities fully. Coordination and communication are the key functions of the compliance officer with regard to planning, implementing and monitoring the compliance program. With this in mind, the OIG recommends the billing company’s compliance officer closely coordinate compliance functions with the provider’s compliance officer.
The compliance officer’s primary responsibilities should include:
• Overseeing and monitoring the implementation of the compliance program; 59
• Reporting on a regular basis to the billing company’s governing body, CEO and compliance committee (if applicable) on the progress of implementation and assisting these components in establishing methods to improve the billing company’s efficiency and quality of services and to reduce the billing company’s vulnerability to fraud, abuse and waste;
• Periodically revising the program in light of changes in the organization’s needs and in the law and policies and procedures of Government and private payer health plans;
• Reviewing employees’ certifications that they have received, read and understood the standards of conduct;
• Developing, coordinating and participating in a multifaceted educational and training program that focuses on the elements of the compliance program and seeks to ensure that all appropriate employees and management are knowledgeable of, and comply with, pertinent Federal and State standards;
• Coordinating personnel issues with the billing company’s human resources/ personnel office (or its equivalent) to ensure that providers and employees do not appear in the Cumulative Sanction Report;60
• Assisting the billing company’s financial management in coordinating internal compliance review and monitoring activities, including annual or periodic reviews of departments;
• Independently investigating and acting on matters related to compliance, including the flexibility to design and coordinate internal investigations (e.g., responding to reports of problems or suspected violations) and any resulting corrective action with all billing departments, providers and sub-providers, agents and, if appropriate, independent contractors;
• Developing policies and programs that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation; and
• Continuing the momentum of the compliance program and the accomplishment of its objectives long after the initial years of implementation.61
The compliance officer must have the authority to review all documents and other information that are relevant to compliance activities, including, but not limited to, patient records (where appropriate), billing records and records concerning the marketing efforts of the facility and the billing company’s arrangements with other parties, including employees, professionals on staff, relevant independent contractors, suppliers, agents, supplemental staffing entities and physicians. This policy enables the compliance officer to review contracts and obligations (seeking the advice of legal counsel, where appropriate) that may contain referral and payment provisions that could violate statutory or regulatory requirements.
In addition, the compliance officer should be copied on the results of all internal audit reports and work closely with key managers to identify aberrant trends in the coding and billing areas. The compliance officer should ascertain patterns that require a change in policy and forward these issues to the compliance committee to remedy the problem. A compliance officer should have full authority to stop the processing of claims that he or she believes are problematic until such time as the issue in question has been resolved.
2. Compliance Committee
The OIG recommends, where feasible,62 that a compliance committee be established to advise the compliance officer and assist in the implementation of the compliance program.63 When assembling a team of people to serve as the billing company’s compliance committee, the company should include individuals with a variety of skills.64
Appropriate members of the compliance committee include the director of billing and the director of coding. The OIG strongly recommends that the compliance officer manage the compliance committee. Once a billing company chooses the people that will accept the responsibilities vested in members of the compliance committee, the billing company must train these individuals on the policies and procedures of the compliance program.
The committee’s responsibilities should include:
• Analyzing the organization’s regulatory environment, the legal requirements with which it must comply 65 and specific risk areas;
• Assessing existing policies and procedures that address these areas for possible incorporation into the compliance program;
• Working with appropriate departments to develop standards of conduct and policies and procedures that promote allegiance to the company’s compliance program; 66
• Recommending and monitoring, in conjunction with the relevant departments, the development of internal systems and controls to carry out the organization’s standards, policies and procedures as part of its daily operations;
• Determining the appropriate strategy/approach to promote compliance with the program and detection of any potential violations, such as through hotlines and other fraud reporting mechanisms;
• Developing a system to solicit, evaluate and respond to complaints and problems; and
• Monitoring internal and external audits and investigations for the purpose of identifying troublesome issues and deficient areas experienced by the billing company and implementing corrective and preventive action.
The committee may also address other functions as the compliance concept becomes part of the overall operating structure and daily routine.