Lab plan offers tips for do-it-yourself compliance
OIG model shows what it’s looking for
The Washington, DC-based Office of Inspector General (OIG) has unveiled a Model Compliance Plan for Clinical Laboratories that provides some specific guidelines on steps hospitals can take to minimize the risk of federal prosecution over claims and billing misdeeds.
The 12-page plan, prepared by the OIG in concert with other federal agencies and the private sector, is directed specifically at laboratories, but also offers valuable insights into features the agency expects in all compliance plans.
The model was developed as part of the government’s Lab Unbundling Project, also called "Labscam." More than 2,000 hospitals have been targeted by the OIG for illegally unbundling Medicare and Medicaid outpatient lab charges.
The guidelines are the government’s suggestions on how to correct and prevent fraudulent practices, and they can be tailored to fit individual situations, the agency says.
Key features of the model include:
• Adopt written procedures and policies.
These should be given to all affected employees. The OIG even suggests they be put in a three-ring binder so amendments and additions can be added. The policies should include:
Standards of conduct. These should help employees determine policies regarding fraud, waste, abuse, and adherence to all federal guidelines. They also should prepared in as many different languages as necessary.
Medical necessity. Be prepared to prove that claims are backed up by proof of medical necessity. Proper documentation can include requisition forms containing diagnosis codes. Also be prepared to educate physicians about their need to document medical necessity. The guidelines state that all laboratories should provide annual written notices to physicians delineating the lab’s policies on medical necessity and details about its billing policies. Each physician also should sign an acknowledgement that he or she is familiar with the policies.
• Comply with OIG fraud alerts.
Include these in the policy manuals, and immediately correct any deficiencies the alerts affect.
• Retain your records.
"One of the best ways to confirm that a compliance plan is effective is through reports that reflect results," the OIG model states. But make sure you address patient confidentiality issues, it warns.
• Tie compliance with performance.
When managers and supervisors are given their performance evaluations, the degree with which they acted on and promoted the compliance plan should be considered.
• Educate and train.
Employees should be given compliance and ethics training annually. Workers should not only be educated about what’s in the plan, but also told that their continued employment depends on following the guidelines.
• Create a hotline.
This could include a telephone hotline, e-mail, or written communication, but a telephone hotline might be best, the model plan states. Notices should be posted informing workers of the hotline number.
• Audit and monitor.
Conduct regular systematic audits of operations. This should include visits to all pertinent sites, interviews with the people doing the work, a review of written materials and documentation, and a trend analysis.
And according to some authorities, it’s worse to have a compliance plan you don’t enforce than to not have one. The model plan admits that the OIG "will be critical of compliance plans and programs that exist on paper but are not earnestly implemented or enforced."
[Editor’s note: A copy of the Model Compliance Plan for Clinical Laboratories is available on the Internet at http://www.sbuonline.sba.gov/ignet/internal/hhs/hhs.html.]
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