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The Office of the Inspector General (OIG) released, on September 25th, the "Final Compliance Program Guidance for Individual and Small Group Physician Practices." The OIG only took three months to finalize the "draft" guidelines. This short turnaround time may be a new record for the OIG and reinforces the importance of compliance programs. The guidelines define a "physician" as: (1) a doctor of medicine or osteopathy; (2) a doctor of dental surgery or of dental medicine; (3) a podiatrist; (4) an optometrist; or (5) a chiropractor, all of whom must be appropriately licensed by the State.

The OIG web site is located at www.dhhs.gov/oig. The web site allows you to see a list of individuals and/or entities who are excluded from participating in Medicare, Medicaid and any other federally funded program. You can access excluded New Jersey physicians on the OIG web site by utilizing the following steps: (1) click on "OIG Electronic Reading Room"; (2) click on "OIG Exclusions"; (3) click on "Online Searchable Database"; (4) click on "Search"; (5) in the General dropdown box choose "Medical Practice"; and (6) in the State box choose "New Jersey." Click Search.

A written plan based on an assessment of a practice’s high-risk areas is the first step in developing an effective Compliance Program. The plan outlines the central features of the program and refers to the OIG’s "seven core elements." The mere existence of a plan provides no protection, unless the action items stated in the plan have been successfully implemented. The combination of a plan and the implementation of its key features comprise a program.

The OIG maintains that a practice should follow the following steps to develop a Compliance Program:

1. Auditing and Monitoring — A physician practice should consistently monitor its activities to insure that its Compliance Program is being implemented. There are two types of reviews that can be performed as part of this evaluation: (a) a standards and procedures review; and (b) a claims submission audit.
2. Establish Practice Standards and Procedures — The following risk areas need to be reviewed as part of establishing policies and procedures: (a) coding and billing; (b) reasonable and necessary services; (c) documentation of services rendered; (d) improper inducements, kickbacks and self-referrals; and (e) retention of records.
3. Designate a Compliance Contact(s) — A member or members of the physician practice needs to accept the responsibility of supervising the monitoring and implementation of the Compliance Program. This responsibility can be shared among physicians and staff.
4. Conduct Appropriate Training and Education — Training must be provided for the following items to insure that the Compliance Plan becomes a Compliance Program: (a) Compliance Program training; (b) coding and billing training; and (c) continuing education on Compliance Program updates.
5. Responding to Detected Offenses and Developing Corrective Action Initiatives — A practice needs to monitor its activities in order to determine if any violations have occurred. An appropriate response to a violation would include the implementation of a corrective action plan.
6. Developing Open Lines of Communication — Physicians and staff should report, through a user-friendly process, conduct that a reasonable person would believe to be erroneous or fraudulent.
7. Enforcing Disciplinary Standards Through Well - Publicized Guidelines — Incorporate policies into the practice to insure that physicians and staff understand the consequences of noncompliant behavior.

A truly effective Compliance Program is one in which both the plan design and the program’s operation are fully supported by detailed documentation that becomes an integral part of the management process of the practice. Once a Compliance Program is successfully implemented, the culture of a practice will shift to reflect the features covered in the plan.

For physician group practices already overburdened with the multitude of requirements imposed on them by various governmental agencies and insurance companies, the prospect of adding yet another chore may seem intimidating. The Amper Healthcare Consulting Group has the knowledge and expertise to ease the process of developing your Compliance Program.

The Amper approach to developing an effective and successful Compliance Program begins with an assessment of the practice’s high risk areas, as outlined by the OIG. It continues with assistance in developing the various elements of the compliance plan, including the mission statement, shareholders resolution, code of ethics and policies and procedures. The final step assists with the implementation of the action items outlined in your plan. These include services such as coding and documentation review, physician and staff training, and an annual audit of your Compliance Program.