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No longer an option Feds now require antifraud compliance plan

BY CRYSTAL ZUZEK The U.S. Department of Health and Human Services Of- fice of Inspector General (OIG) used to encourage physicians in Medicare and Medicaid to adopt volun- tary compliance programs. But now it’s the law. Under the Patient Pro- tection and Affordable Care Act (PPACA), compliance programs are no longer voluntary. As a condition of enrollment in federal health programs, includ- ing Medicare and Medicaid, the health system reform law requires physicians to establish a compliance pro- gram that features specific core elements.

In the fall, the Texas Health And Human Ser- vices Commission (HHSC) released final rules on Med- icaid compliance programs, including enforcement pro- visions that allow HHSC to levy administrative penal- ties or sanctions against those who fail to establish an “effective compliance program for detecting crim-

that provides a vehicle for improvement when neces- sary,” he said.

Family physician Greg Sheff, MD, is medical director of care manage- ment and clinical integration for Austin Regional Clinic, which has had a compliance program in place for 10 years.

inal, civil, and administrative violations.” The rules (online at took effect Oct. 14, 2012. Family physician Greg Sheff, MD, is medical director of care management and clinical integration for Austin Regional Clin- ic (ARC), which has had a compliance program for 10 years — long before the federal mandate. “At ARC, we’ve seen the value in having a structured process that helps ensure we’re operating in line with regulations and

Amanda Hill, an Austin attorney and former ARC general counsel, says a ro- bust compliance program can help physicians avoid prosecution for health care fraud if a federal agency investigates them. “The federal govern- ment will show no leni- ency if a medical practice doesn’t have a compliance program. Physicians need to develop a written plan that details how they au- dit for possible billing and coding errors and correct mistakes. They also need to ensure implementation of the plan and update it regularly,” Ms. Hill said. Dr. Sheff has advice for physicians who are just getting started on their compliance program. “Start by cultivating a medical practice culture that is committed to com- pliance and to addressing any concerns that arise. After that, the practice will

want to appoint a compliance officer or team and provide edu- cation on the compliance process,” he said. Establishing a compliance program doesn’t have to be a major strain on a medical practice, but it does require some training and customization. “The program doesn’t have to be elaborate and complex. But at the same time, physicians shouldn’t just pull a boiler plate plan off the Internet. I’d rather see a bare-bones program a



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