Executive Vice President's Report Do You Have A Medicare Compliance Plan? Philip H. Gilbert, Executive Vice President

Those of you who are involved in providing patient care to those insured through federal health benefits programs need to stay aware of the government's fraud enforcement activities. The media is covering more and more horror stories about the enforcement activities against hospitals, clinical laboratories, durable medical equipment supplies, hospices, and home health agencies. Do not think for one moment that physicians are going to be passed over.

What can you do to protect your self from the sometimes out of control totally irrational enforcement arm of the government? Establish and maintain a compliance plan for your practice is the recommended answer that will help you in avoiding activities that could be attacked under the fraud and abuse laws.

The model Medicare/Medicaid Fraud and Abuse Compliance plan developed by Bruce D. Blehart, J.D. Office of General Counsel American Medical Association stresses seven elements an effective compliance plan should include:

1. A clear commitment to compliance. A compliance plan must ensure that everyone in the organization understands the obligation to comply with the established and understood standards and the organization will take action to uphold those standards.

2. Appointment of a trustworthy compliance officer with a high level responsibility. The compliance officer will be considered to have the requisite authority if he or she is able to influence behavior and organizational practices.

3. Effective training and education programs. There must be a routine training and education process that addresses the role of everyone involved in the organization and makes participation in the compliance program understandable.

4. Auditing and monitoring. There must be a regular review of the organization's claim development and submission process from the point where a service for a patient is initiated to the submission of a claim for payment. The monitoring process includes a methodology to facilitate employee reporting of suspected situations of fraud or abuse.

5. Communications. Organizations must maintain an effective communication process, including a hotline procedure to facilitate reporting of suspected violations.

6. Internal investigation and enforcement. Organizations must be able to conduct an appropriate investigation and take disciplinary actions.

7. Response to identified offenses and application of corrective action initiatives. On the identification of a compliance problem, organizations have a responsibility to take demonstrable corrective action, including steps to prevent further similar offenses.

The central component of an effective plan is still documentation, documentation, documentation!

I have a copy of the AMA's model as prepared by Bruce D. Blehart, JD. If you would like a copy just, call (355-6561) fax (353-5848) or e-mail (dcms@jaxmed.com) and let me know where to send it.

April 1998 / Jacksonville Medicine

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