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Benefits of a Compliance Program

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

A. Benefits of a Compliance Program

The OIG believes an effective compliance program provides a mechanism that brings the public and private sectors together to reach mutual goals of reducing fraud and abuse, improving operational quality, improving the quality of health care and reducing the costs of health care. Attaining these goals provides positive results to business, Government and individual citizens alike. In addition to fulfilling its legal duty to ensure that it is not submitting false or inaccurate claims to Government and private payers, a billing company may gain numerous additional benefits by implementing an effective compliance program. These benefits may include:

  • The formulation of effective internal controls to assure compliance with Federal regulations, private payer policies and internal guidelines;
  • Improved medical record documentation;
  • Improved collaboration, communication and cooperation among health care providers and those processing and using health information;
  • The ability to more quickly and accurately react to employees’ operational compliance concerns and the capability to effectively target resources to address those concerns;
  • A more efficient communications system that establishes a clear process and structure for addressing compliance concerns quickly and effectively;
  • A concrete demonstration to employees and the community at large of the billing company’s strong commitment to honest and responsible corporate conduct;
  • The ability to obtain an accurate assessment of employee and contractor behavior relating to fraud and abuse;
  • Increased likelihood of identification and prevention of criminal and unethical conduct;
  • A centralized source for distributing information on health care statutes, regulations and other program directives related to fraud and abuse and related issues;
  • A methodology that encourages employees to report potential problems;
  • Procedures that allow the prompt, thorough investigation of possible misconduct by corporate officers, managers, employees and independent contractors, who can impact billing decisions;
  • An improved relationship with the applicable Medicare contractor;
  • Early detection and reporting, minimizing the loss to the Government from false claims, and thereby reducing the billing company’s exposure to civil damages and penalties, criminal sanctions, and administrative remedies, such as program exclusion; and
  • Enhancement of the structure of the billing company’s operations and the consistency between separate business units.

Overall, the OIG believes that an effective compliance program is a sound business investment on the part of a billing company.

The OIG recognizes the implementation of an effective compliance program may not entirely eliminate fraud, abuse and waste from an organization. However, a sincere effort by billing companies to comply with applicable Federal and State standards, as well as the requirements of private health care programs, through the establishment of an effective compliance program, significantly reduces the risk of unlawful or improper conduct.