Years ago, the federal judiciary realized that federal judges needed sentencing guidelines for healthcare fraud. In the process, they issued compliance guidelines for different healthcare industries. Each incorporates the seven elements of compliance to combat healthcare fraud. The ramifications of violating the false claims act are tremendous. So what do you need to do to protect your dental practice? What are the seven elements that need to be incorporated into compliance programs? Listen to this episode of Talking with the Toothcop to find out!
Outline of This Episode
- [10:22] The evolution of compliance programs
- [12:27] The 7 elements of compliance programs
- [16:21] #1: Implement written policies and procedures
- [21:50] #2: Designate a compliance officer
- [24:53] #3: Provide effective compliance training
- [30:16] #4: Develop effective lines of communication
- [36:08] #5: Conduct internal monitoring and auditing
- [43:38] #6: Enforce standards through disciplinary guidelines
- [44:56] #7: Respond promptly to violations and take corrective action
- [47:54] #8: Whistleblower protections in New York state
- [50:41] Give us some feedback! How can we serve you better?
What are the seven core elements of a compliance program?
Every healthcare provider that participates with Medicare or Medicaid has to establish a healthcare compliance program that incorporates these seven elements:
- Implement written policies and procedures
- Designate a compliance officer and compliance committee
- Conduct effective compliance training and education
- Develop effective lines of communication
- Conduct internal monitoring and auditing
- Enforce standards through well-publicized disciplinary guidelines
- Respond promptly to violations and take timely corrective action
Any organization that has been busted for healthcare fraud—rather than being kicked out of the Medicaid program—has to establish a compliance program. It also comes with a babysitter for 5 years and compliance with a Corporate Integrity Agreement. It’s five years of probation. It’s also why it’s imperative that you read, understand, and implement each of these elements.
Implement written policies and procedures
You need to create policies and procedures for whatever compliance risks you face as a practice. Some of the risks you might face could be related to sedation (general anesthesia), patient information and HIPAA regulations, infection control, electronic billing reference materials (CDT coding books), controlled substances/drug policies, medical emergencies and much, much more.
You need to identify your risk areas and write policies and procedures to serve as a reference guide for your staff. How do you establish them? Write down a brain-dump list of every risk you can think of that your dental practice might face. Ask the questions: Can I lose money? Can I lose my license? Can I lose freedom? If you can answer yes to any of those questions, it’s time to frame up some policies and procedures.
The bottom line is that the government wants to see that you have policies and procedures in place to deal with overpayments and your response to an identified overpayment. Andrea and I take a deep-dive into element #2—so keep listening.
Provide effective compliance training and education
There are certain things every staff member should be trained on including code of conduct training, fraud, waste, & abuse training, continued education for billing staff, OSHA and HIPAA training, infection control training, and more. It’s your job to figure out what needs to be done and who needs to complete it. It’s not an excuse to say “I didn't know.”
The code of conduct is somewhat of a catch-all. You can’t predict every situation that might happen in your practice. It’s just not possible. Your written code of conduct is a set of principles that you want your staff to use to problem-solve. It should communicate your practice’s values, mission, vision, and purpose. Train your new employees on your code of conduct immediately. Effective training isn’t just giving someone information—you have to make sure they’re retaining the information, too.
Keep listening to hear why element #4—developing effective lines of communication—is so important.
Conduct internal monitoring and auditing AND enforce corrective action
Two elements absolutely HAVE to be implemented—number #5 & #7. They involve checking your work—and fixing your mistakes. Having both processes in place is important. You need people in place to keep things in check. Put systems in place to track and stay on top of those things that you need to monitor.
Review your employee handbook periodically and update it to reflect current regulations. It should outline disciplinary guidelines. Many follow a progressive guideline such as a write-up, suspension, time off without pay, etc that leads up to termination—while reserving the right to fire when necessary. It needs to be well-published and applied evenly and fairly at every level of the organization. If you have a bad apple, you have a responsibility to carve them out of your organization before they harm someone.
Listen to the rest of the episode to hear about element #6 as well as the important topic of exclusion monitoring—if you don’t do this you can bankrupt your business.
Resources & People Mentioned
- The False Claims Act
- Office of the Inspector General Website
- Corporate Integrity Agreements
- OIG Compliance for Individual and Small Group Physician Practices
- HEAT Provider Compliance Training Videos
- Measuring Compliance Program Effectiveness: A Resource Guide