OIG issues voluntary compliance guidance
The Department of Health and Human Services’ Office of Inspector General (OIG) has issued final guidance to help physicians in individual and small group practices design voluntary compliance programs.
"The intent of the guidance is to provide a road map to develop a voluntary compliance program that best fits the needs of that individual practice," Inspector General June Gibbs Brown said in releasing the guidance. "The guidance itself provides great flexibility as to how a physician practice could implement compliance efforts in a manner that fits with the practice’s existing operations and resources."
Brown said the OIG hopes to encourage physician practices to adopt the active application of compliance principles rather than implement rigid, costly, formal procedures. The goal of the guidance is to show physician practices that compliance can become a part of the practice culture without the practice having to expend substantial monetary or time resources, she says.
"The OIG believes the great majority of physicians are honest and committed to providing high-quality medical care to Medicare beneficiaries," Brown said.
Under the law, physicians are not subject to civil, administrative, or criminal penalties for innocent errors or even negligence. The government’s primary enforcement tool, the civil False Claims Act, covers only offenses that are committed with knowledge of the falsity of the claim or with reckless disregard or deliberate ignorance of the truth or falsity of a claim. The False Claims Act does not cover mistakes, errors, or negligence. The OIG is very mindful of the difference between innocent errors ("erroneous claims") and reckless or intentional conduct ("fraudulent claims"), Brown says.
Unlike other guidance previously issued by the OIG, the final physician guidance does not suggest that physician practices implement all seven standard components of a full-scale compliance program. While the seven components provide a solid basis upon which a physician practice can create a compliance program, the OIG acknowledges that full implementation of all components may not be feasible for smaller physician practices. Instead, the guidance emphasizes a step-by-step approach for those practices to follow in developing and implementing a voluntary compliance program. As a first step, physician practices can begin by identifying risk areas that, based on a practice’s specific history with billing problems and other compliance issues, might benefit from closer scrutiny and corrective/educational measures.
This is how the OIG describes the step-by-step approach: 1) conducting internal monitoring and auditing through the performance of periodic audits; 2) implementing compliance and practice standards through the development of written standards and procedures; 3) designating a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards; 4) conducting appropriate training and education on practice standards and procedures; 5) responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate government entities; 6) developing open lines of communication, such as community bulletin boards and discussions at staff meetings, to keep practice employees updated on erroneous or fraudulent conduct issues as well as compliance activities;
7) enforcing disciplinary standards through well-publicized guidelines.
A glance at the final guidance
The final guidance identifies four specific compliance risk areas for physicians. They reflect areas in which the OIG has focused its investigations and audits related to physician practices: 1) proper coding and billing; 2) ensuring that services are reasonable and necessary; 3) proper documentation; 4) avoiding improper inducements, kickbacks, and self-referrals.
Recognizing the financial and staffing resource constraints faced by physician practices, the final guidance stresses flexibility in the manner a practice implements voluntary compliance measures. The OIG encourages physician practices to participate in the compliance programs of other providers, such as hospitals or other settings in which the physicians practice. A physician practice’s participation in such compliance programs could be a way, at least partly, to augment the practice’s own compliance efforts.
Needs of larger practices
The final guidance also provides direction to larger practices in developing compliance programs by recommending that they use both the physician guidance and previously issued guidance, such as the Third-Party Medical Billing Company Compliance Program Guidance or the Clinical Laboratory Compliance Program Guidance, to create a compliance program that meets the needs of the larger practice.
The final guidance includes several appendices outlining additional risk areas about which various physicians expressed interest, as well as information about criminal, civil, and administrative statutes related to the federal health care programs. The guidance also includes information about the OIG’s provider self-disclosure protocol and Internet resources that may be useful to physician practices.
The final physician guidance is available on the Office of Inspector General’s Web site at www.hhs.gov/oig.
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