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RISK MANAGEMENT

New compliance guidance for organizations helpful for medical offices

On April 20, 2015, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) issued a compliance guidance document designed to help boards of directors at health care organizations make sure management is effective in implementing compliance programs. While the document is intended for boards of directors, the suggestions and tips for improving compliance oversight can also be applied by medical offices to make sure compliance efforts are up to date and effective. 

The introduction emphasizes that effective compliance oversight requires “asking the right questions of management to determine the adequacy and effectiveness of the organization’s compliance program, as well as the performance of those who develop and execute that program, and to make compliance a responsibility for all levels of management.” That’s important for all health care providers of all sizes.

Here are some of the tips and suggestions relevant for medical offices:

  • Use existing guidance materials such as the OIG compliance program guidance and Corporate Integrity Agreements as “benchmarks” for evaluating the effectiveness of compliance plans.
  •  Keep up with developments in compliance and identify new compliance risks by using compliance hotlines and internal audits and monitoring “professional organization publications, OIG-issued guidance, consultants, competitors, or news media.”
  • Take note of enforcement cases against other physicians, physician groups, and other providers, and then check if your medical office has “controls and processes in place to reduce the risk of, and to identify, similar misconduct or issues.”
  • Use data available through the Sunshine Law, and CMS payment and quality data to establish benchmarks and compare your practice to others.
  • Promote a culture of compliance, audit, and self-report noncompliance and repay overpayments.

It’s worth noting that among the top risk areas highlighted, the first issue mentioned is referral relationships and arrangements—an issue of significant relevance to physician practices who refer patients to other providers, such as laboratories. Other risk areas highlighted are billing, privacy breaches, and quality-related events.

Highlighting the potential for “new incentives and compliance risks” created by current health care reform efforts, the guidance notes: “New payment models have also incentivized consolidation among health care providers and more employment and contractual relationships (e.g., between hospitals and physicians).” The guidance advises entities that have financial relationships with referral sources—such as physicians—to “ask how their organizations are reviewing these arrangements for compliance with the physician self-referral (Stark) and anti-kickback laws.” That’s also extremely important for medical offices whose physicians are sources of referrals to other entities.

The resource, “Practical Guidance for Health Care Governing Boards on Compliance Oversight,” was created through the joint efforts of the OIG, the American Health Lawyers Association (AHLA), the Association of Healthcare Internal Auditors (AHIA), and the Health Care Compliance Association (HCCA). It can be found on the OIG’s website.

Medical office managers who are involved with implementing or overseeing compliance programs should consider this document as another resource for making compliance efforts as effective as possible.


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