Compliance Programs

HNS has developed a compliance program to establish a culture that promotes prevention, detection and resolution of instances of conduct that do not conform to federal and state law, and federal, state and private payor health care program requirements and HNS' ethical and business policies.

An important step in protecting your practice is the development of a compliance plan for your own office.

HNS contracted health care professionals are required to develop their own voluntary compliance programs.  Voluntary compliance programs serve as a positive step towards assisting physicians in preventing the submission of erroneous claims or engaging in unlawful conduct involving the federal health care programs and in preventing HIPAA violations.

The Office of Inspector General (OIG) has published voluntary compliance program guidance for individual and small group physician practices.  This guidance can be found at https://oig.hhs.gov/authorities/docs/physician.pdf.

A compliance plan should clearly indicate your commitment to proper coding, billing and documentation, to payor policies and all state and federal regulations, including HIPAA privacy rules concerning protected health information.  HNS recommends that your compliance plan state that your practice has zero tolerance for violations of FWA and HIPAA laws, and HNS and HNS Payor Policy.

An effective compliance plan should include the following seven elements:

• Written policies and procedures.
  

   

• Designation of a compliance officer.
  

   

• Training and education.
  

   

• Effective communication.
  

   

• Internal monitoring and auditing.
  

   

• Employee discipline.
  

   

• Response to detected violations.
  

   

1. The written policies and procedures should indicate the practice's commitment to the compliance plan and should outline ways the practice intends to combat any fraudulent or abusive actions and HIPAA violations.  The provider should identify risk areas to the practice and design policies and procedures to limit or reduce those risks and the procedure should support the policies in your plan.  The areas of greatest concern are coding and billing, documentation, kickbacks and inducements and HIPAA violations.
   

    

2. To be effective, your compliance plan should include the designation of a compliance officer who can monitor and enforce the compliance plan.  The plan will have no value without monitoring and enforcement.  This person should be experienced in proper documentation, coding and billing, industry standards and state and federal regulations.
   

    

3. Training and education are vital to a successful and effective compliance plan.  Without training and education, employees will not understand the policies and cannot be expected to follow the compliance plan.  Training and education for each employee should be documented and employees should know that compliance is required for continued employment with your practice.  Training schedules should be included in the plan, such as annual training for all employees and an established time frame for training all new employees.
   

    

4. Effective lines of communication are necessary for a sound compliance plan and practices must encourage open communication between the compliance officer, the employees and the provider.  Employees must understand the importance of reporting any incident they believe might be erroneous, fraudulent or a violation of any state or federal regulation.  Employees should report any concerns without fear of retribution and should further understand that failure to report concerns is a violation of the compliance plan.
   

    

5. Internal monitoring and auditing is the heart of a successful compliance plan.  Conducting audits helps monitor the effectiveness of the plan and helps identify areas that need improvement.
   

    

6. To be effective, the practice must enforce the compliance plan.  There should be clearly written sanctions for non-compliance or for not reporting a suspected problem.  Sanctions might include oral warnings, written warnings, probation, etc.
   

    

7. Having a compliance plan and not enforcing it can be more dangerous than not having one at all!  By not enforcing it, the provider demonstrates his lack of commitment to preventing fraud and abuse.  If a compliance plan does not detect violations and problems, it is not effective and should be re-evaluated for improvement.

    

We have provided you with this compliance plan overview, and an outline of required elements, to assist you with developing your own compliance plan.  There are many additional resources available to further assist you with your compliance plan, including software, program templates, as well as consulting companies who specialize in the development of a sound, practice-specific compliance program.