October 1999 Bulletin

You have compliance plan, now use it

Personnel coding and billing manuals are basic documents; baseline audit will help activate plan

By Susan Sterman

Several months ago at a seminar on compliance for a group of practice administrators, I asked the group who among them had a compliance program in place. A young woman raised her hand and said, "I have 20 compliance programs in my office and I still have no idea how to implement one." It turned out that she had stacks of books, manuals and seminar material focusing on compliance; and every afternoon at 5:30 or so she would sit down and plow through the information, trying to understand how to put a program into place for her practice.

Compliance has become the bane of existence for practice administrators. It need not be. Almost all administrators already have compliance standards in place in their practices, they just don't know it yet.

Do you have a personnel manual in your practice? Do you have a coding and billing manual? If so, then you have the basic compliance documents in place. The only thing left to do is implement the procedures you already have in place.

A compliance program is a mechanism to identify activities in a practice that may subject the practice to sanctions. Before you can establish any plan you must identify where the practice is in relation to the rules, regulations, policies and programs which govern medical practices. This requires a review of the practice's standards and the way that the practice is functioning with regard to those standards. This is known as a baseline audit. Once this audit is done, you will have the information necessary to put your compliance plan into place.

You too can do this simply. You do it by making sure that someone-the compliance officer-oversees the achievement of the standards that you have in place. You do it by assuring that the people involved in areas of concern-billing, referrals, coding, lab, etc.-don't have a history of illegal activities. You ensure that the members of the practice, including physicians, understand the standards and what is required of each of them in the performance of their jobs (job descriptions and training).

You monitor and audit your billing, medical records and other areas of concern and give your personnel a way to tell you of a problem that does not put them a risk for their positions (anonymous reporting). You discipline those who break the rules, including those who failed to detect or report a violation, in a consistent fashion and, if you find that a violation of the standards has occurred, you modify the training as necessary so that the breach should not happen again. Finally, as every administrator knows, standards, training, reporting, investigation and resolution must be documented. If it's not documented, it did not happen.

Compliance programs are good business and this fact will help get your team behind the program. Billing audits enable the practice to determine if coding and billing is done appropriately and will maximize reimbursement to the practice. Chart reviews will show documentation issues. This will help limit the liability issues for a practice. Personnel who are given straightforward guidelines on performance of their duties and a mechanism for resolving concerns are more comfortable in their jobs. Compliance programs should increase employee morale and pride. The foundation is, of course, management's commitment to honest, ethical and professional conduct in all aspects of the practice.

A word of caution. There is another name for compliance programs that exist only on paper, and that name is evidence-evidence of your knowledge of the rules and regulations and evidence of the practice's failure to implement and abide by those rules and regulations. If the entire practice does not have a commitment to complying with ethical practice standards then the practice is better off not having a compliance program in place. If you create one, use it often.

Susan Sterman, JD, is a health care attorney for The Physician's Advocate in Flagstaff, Ariz.

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