Compliance Programs

In the highly regulated area of healthcare, it is important for providers to take a proactive approach to billing and documentation compliance.  Our attorneys work with providers to identify potential risk areas and develop a responsive compliance plan in order to successfully minimize those risks.  The implementation of an effective compliance plan can put a health care provider in the best position to defend against an audit or other third party inquiry.  Having an effective compliance program in place can also reduce culpability under the Federal Sentencing Guidelines.  The Affordable Care Act makes compliance programs compulsory for certain industry segments, although regulations are still pending. For those providers not yet required to have compliance programs, the OIG has encouraged the implementation of compliance programs for years by frequently issuing industry specific guidance.

When developing a compliance plan for a healthcare provider, we first seek to gain an understanding of the particular practice and the specific risks it faces.  With this understanding, we then identify and analyze the applicable billing, documentation and coverage policies issued by Medicare and other third party payors. We also work with outside experts and consultants to provide an independent review of your entity’s documentation under attorney client privilege when appropriate.

Armed with the policies and guidelines with which your entity is expected to comply and an understanding of your current documentation and billing practices, our attorneys will develop a practical compliance plan for your office. The compliance plan will outline a code of conduct for your organization as well as billing and documentation policies and procedures to be implemented by your staff in an effort to minimize the risks of overpayments or improper claim submissions.

Compliance requires ongoing effort; it does not begin and end with the development of a compliance plan.  Once the compliance plan has been developed, it is imperative to train your staff to implement the policies and procedures in day-to-day practice.  We can assist your office in developing a training program to effectively implement the compliance plan.  And because healthcare regulations and guidance are constantly changing, we can work with your staff to periodically check for updates or changes in the applicable documentation, coverage and billing policies and incorporate continuing education opportunities.

Compliance activities can also raise issues related to the reporting and return of known overpayments. Because the failure to timely report and return identified overpayments can result in liability under the Federal False Claims Act, it is important for providers to consult with counsel when issues of this nature arise.  We can assist providers in understanding their statutory and regulatory obligations and in drafting a disclosure should it become necessary to report and return monies.