Enforcing Standards Through Well-Publicized Disciplinary Guidelines

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

E. Enforcing Standards Through Well-Publicized Disciplinary Guidelines

1. Discipline Policy and Actions
An effective compliance program should include guidance regarding disciplinary action for corporate officers, managers and employees who have failed to comply with the billing company’s standards of conduct, policies and procedures, Federal, State or private payer health care program requirements, or Federal and State laws, or those who have otherwise engaged in wrongdoing, which has the potential to impair the billing company’s status as a reliable, honest and trustworthy organization.

The OIG believes the compliance program should include a written policy statement setting forth the degrees of disciplinary actions that may be imposed upon corporate officers, managers and employees for failing to comply with the billing company’s standards and policies and applicable statutes and regulations. Intentional or reckless noncompliance should subject transgressors to significant sanctions. Such sanctions could range from oral warnings to suspension, termination or financial penalties, as appropriate. Each situation must be considered on a case by-case basis to determine the appropriate sanction. The written standards of conduct should elaborate on the procedures for handling disciplinary problems and identify who will be responsible for taking appropriate action. Some disciplinary actions can be handled by department managers, while others may have to be resolved by a senior manager. Disciplinary action may be appropriate where a responsible employee’s failure to detect a violation is attributable to his or her negligence or reckless conduct. Personnel should be advised by the billing company that disciplinary action will be taken on a fair and equitable basis. Managers and supervisors should be made aware that they have a responsibility to discipline employees in an appropriate and consistent manner.

It is vital to publish and disseminate the range of possible disciplinary actions for improper conduct and to educate officers and other staff regarding these standards. The consequences of noncompliance should be consistently applied and enforced for the disciplinary policy to have the required deterrent effect. All levels of employees should be subject to the same disciplinary action for the commission of similar offenses. The commitment to compliance applies to all personnel levels within a billing company. The OIG believes that corporate officers, managers and supervisors should be held accountable for failing to comply with, or for the foreseeable failure of their subordinates to adhere to, the applicable standards, laws, rules, program instructions and procedures.

2. New Employee Policy
For all new employees who have discretionary authority to make decisions that may involve compliance with the law or compliance oversight, billing companies should conduct a reasonable and prudent background investigation, including a reference check, as part of every such employment application. The application should specifically require the applicant to disclose any criminal conviction, as defined by 42 U.S.C. 1320a-7(i), or exclusion action. Pursuant to the compliance program, billing company policies should prohibit the employment of individuals who have been recently convicted of a criminal offense related to health care or who are listed as debarred, excluded or otherwise ineligible for participation in Federal health care programs.83 In addition, pending the resolution of any charges or proposed debarment or exclusion, the OIG recommends that such individuals should be removed from direct responsibility for, or involvement, in any Federal health care program.84 Similarly, with regard to current employees or independent contractors, if resolution of the matter results in conviction, debarment or exclusion, then the billing company should remove the individual from direct responsibility for or involvement with all Federal health care programs.