Application of Compliance Program Guidance

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. Application of Compliance Program Guidance

Given the diversity in size and services offered by billing companies within the industry, there is no single ‘‘best’’ compliance program. The OIG understands the variances and complexities within the industry and is sensitive to the differences between large and small billing companies. Similarly, the OIG understands the availability of resources for any one billing company can differ vastly, given that billing companies vary greatly in the type of services offered and the manner that they are provided. Nonetheless, elements of this guidance can be used by all billing companies, regardless of size, location or corporate structure, to establish an effective compliance program. The OIG recognizes some billing companies may not be able to adopt certain elements to the same comprehensive degree that others with more extensive resources may achieve. This guidance represents the OIG’s suggestions on how a billing company can best establish internal controls and monitor company conduct to correct and prevent fraudulent activities. By no means should the contents of this guidance be viewed as an exclusive discussion of the advisable elements of a compliance program. On the contrary, the OIG strongly encourages billing companies to develop and implement compliance elements that uniquely address the individual billing company’s risk areas.

The OIG appreciates that the success of the compliance program guidance hinges on thoughtful and practical comments from those individuals and organizations that will utilize the tools set forth in this document. In a continuing effort to collaborate closely with the private sector, the OIG solicited input and support from representatives of the major trade associations in the development of this compliance program guidance. Further, we took into consideration previous OIG publications, such as Special Fraud Alerts,10 the recent findings and recommendations in reports issued by OIG’s Office of Audit Services, comments from the HCFA, as well as the experience of past and recent fraud investigations related to billing companies conducted by OIG’s Office of Investigations and the DOJ.

As appropriate, this guidance may be modified and expanded as more information and knowledge is obtained by the OIG, and as changes in the law, and in the rules, policies and procedures of the Federal, State and private health plans occur. The OIG understands billing companies will need adequate time to react to these modifications and expansions and to make any necessary changes to their voluntary compliance programs. New compliance practices may eventually be incorporated into this guidance if the OIG discovers significant enhancements to better ensure an effective compliance program. We recognize the development and implementation of compliance programs in billing companies often raise sensitive and complex legal and managerial issues.11 However, the OIG wishes to offer what it believes is critical guidance for those who are sincerely attempting to comply with the relevant health care statutes and regulations.