By Deborah Robinson, Esq.

Published December 2000

Special supplement on
Compliance Program Guidance for Individual and Small Group Physician Practices

• Overview of OIG's MD compliance guidance
  

• Physician compliance plan risk areas
  

• How to deal with compliance lapses
  

• Employee education in compliance programs
  

• Compliance and relationships among providers
  

• React to this article in the Discussion Forum.

Although the OIG continues to stress that such a Program is voluntary, it continues to be a general and growing consensus that adopting a Program will become the standard of care for medical practices. It is the premise of this article that employee education and training will be the cornerstone of any effective Program and is a component in each of the steps outlined by the OIG. Any Compliance Program will, by its definition, need to be personnel intensive and the greatest efforts will be in the area of developing, and continuing to develop effective employee education and training and in monitoring the effectiveness of those efforts.

Initially, the OIG gives guidance generally to practices in identifying the steps necessary to create an effective Compliance Program:

• Conducting internal monitoring and auditing.

• Developing written standards and procedures.

• Designating a Compliance Officer.

• Conducting appropriate employee training and education.

• Responding appropriately to detected violations.

• Developing open lines of communication.

• Enforcing disciplinary standards.

Education as the Cornerstone of Developing a Compliance Program

Although education and training is identified as a separate component of the Program, it essentially forms the basis for the entire process. A first step in effectuating a Program is identified as conducting internal monitoring and auditing. Although this is identified as the first step in developing a Compliance Program, the OIG recommends: "That claims/services that were submitted and paid during the initial three (3) months after implementation of the education and training program be examined so as to give the physician practice a benchmark against which to measure future compliance effectiveness" (emphasis added). Therefore, it is acknowledged from the onset that the initial efforts of the practice are to educate, and continue to educate, its staff.

Developing Written Standards and Procedures

Written standards and procedures are characterized as "a central component of any Compliance Program." If practices do not have adequate policy manuals, the practice can develop its own. In order to facilitate this, the OIG publishes, at the end of the document, a list of resources and web sites where physicians can obtain this information. This information is also generally available from many professional societies. It is important to note, however, that the purpose of developing a policy manual is not to create a manual but to serve as a continuing resource for the education of physicians and other practice employees. Again, the implicit emphasis here is on the continuing responsibility of the practice to update and educate its employees.

Guideline for Developing an Effective Education and Training Program

The actual requirement to establish this component of the Program is quite helpful. According to the OIG recommendations, there are three basic steps for setting up educational objectives to be established under the direction of a Compliance Officer:

• Determining who needs training (both in coding and billing and in compliance).

• Determining the type of training which best suits the practice’s needs (e.g., seminars, in-service training, self study or other programs).

• Determining when and how often education is needed and how much each person should receive.

It is important for the physician practice to recognize that the guidance is extremely flexible in the area of how education can be provided. Education can be provided through in-house training, the distribution of newsletters, and even postings on office bulletin boards. Physician practices with third party billing companies may work collaboratively with the third party billing companies to provide education to assure appropriate documentation for submitting claims. Physicians who are hospital-based physicians can incorporate appropriate hospital Compliance Program educational efforts as part of their compliance efforts.

Although there is no prescription for how often training sessions should occur, the OIG recommends that there be at least annual training programs for individuals involved in coding and billing. New employees should be trained as soon as possible. No practice should be intimidated by the educational requirements but, rather, look at the dissemination of information to appropriate personnel as an appropriate component of practicing in a highly regulated industry.

Communication

The revised guidelines are more flexible in how communication can be established. There is, for example, no requirement that every office have a hot line. In many situations an open door policy will be sufficient.

Although setting up lines of communication is a separate step in the development of a Program, again, education is a critical component. Every employee in a practice is required to understand that, as part of the Program, each employee accepts responsibility for identifying when, in their good faith judgment, there is an erroneous or fraudulent activity. Each practice is also required to communicate to its employees that there will be no retribution for the reporting of such activities. Anonymity should be encouraged although not possible to assure in all cases.

Enforcement of Standards

Another separate component of the compliance process is ensuring that the practice’s Compliance Program will be enforced in a consistent and appropriate manner. Although the guidelines do not prescribe a graduated disciplinary process, there is a specific need for both the physicians and other practice employees to be informed of the practice’s expectations of all employees conforming with the Compliance Program, both as a continuing measure of any performance evaluation and, if necessary, in the institution of disciplinary action. Many practices have developed employee handbooks to educate their employees and these should be reviewed to assure that Compliance Program standards are addressed.

It is a reasonable assumption for any physician practice at this time to understand that it must take certain steps to adopt, implement and sustain a Compliance Program. The OIG guidance provides sufficient leeway for any practice to adopt a Program which is commensurate with its size and needs. No practice will be able to accomplish this without an effective educational program for its employees.

Deborah J. Robinson, Esq., is a director of Houston Harbaugh, P.C. in Pittsburgh.