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For
Dental and Medical Practices
This is a sample only. It is not intended as legal advice.
1.
Commitment to Compliance
•
Standards of Conduct
• Medical Necessity
• Billing
• Reliance on Standing Orders
• Compliance with Applicable HHS
Fraud Alerts
• Marketing
• Anti-Kick Back/Inducements
• Retention of Records/Documentation
2. Designation of a Compliance Officer/Committee
• Compliance
Officer
• Compliance Committee
3. Conducting Training and Education
Programs
4.
Communication
5.
Disciplinary Guidelines
6.
Auditing and Monitoring
7.
Corrective Action
8.
Response to Special Agent's Visit for
the Purpose of Investigating Allegations of Fraud and
Abuse
The Dental or Medical Practice voluntarily implements
a compliance program aimed at fraud, waste, and abuse
prevention while at the same time advancing the mission
of providing quality patient care. Our compliance efforts
are aimed at prevention, detection and resolution of
variances.
The eight elements of the Dental or Medical Practice
Compliance Plan are:
•
Commitment to Compliance
-
Standards of Conduct
- Medical Necessity
- Billing
- Reliance on Standing Orders
- Compliance with Applicable HHS Fraud Alerts
- Marketing
- Anti-Kick Back/Inducements
- Retention of Records/Documentation
•
Designation of a Compliance Officer/Committee
• Conducting Training and Education Programs
• Communication
• Disciplinary Guidelines
• Auditing and Monitoring
• Corrective Action
• Response to Special Agent's Visit for the Purpose
of Investigating Allegations of Fraud and Abuse
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1.
COMMITMENT TO COMPLIANCE
Standards
of Conduct
The
Dental or Medical Practice promotes adherence to the
Compliance Program as a major element in the performance
evaluation of all staff members.
The
Dental or Medical Practice employees are bound to comply,
in all official acts and duties, with all applicable
laws, rules, regulations, standards of conduct, including,
but not limited to laws, rules, regulations, and directives
of the federal government and the state of Florida,
and rules policies and procedures of the Dental or Medical
Practice. These current and future standards of conduct
are incorporated by reference in this Compliance Plan.
All
candidates for employment shall undergo a reasonable
and prudent background investigation, including a reference
check. Due care will be used in the recruitment and
hiring process to prevent the appointment to positions
with substantial discretionary authority persons whose
record (professional licensure, credentials, prior employment,
any criminal record) gives reasonable cause to believe
the individual has a propensity to fail to adhere to
applicable standards of conduct.
All
new employees will receive orientation and training
in compliance policies and procedures. Participation
in required training is a condition of employment. Failure
to participate in required training may result in disciplinary
actions, up to and including, termination of employment.
Every
employee is asked to sign a statement certifying they
have received, read and understand the contents of the
compliance plan.
Every
employee will receive periodic training updates in compliance
protocols as they relate to the employee's individual
duties.
Non-compliance
with the plan or violations will result in sanctioning
of the involved employee(s) up to, and including, termination
of employment.
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Medical
Necessity
The
Dental or Medical Practice will take reasonable measures
to ensure that only claims for services that are reasonable
and necessary, given the patient's condition, are billed.
Documentation
will support the determinations of medical necessity
when providing services.
The
Dental or Medical Practice is aware that Medicare will
only pay for tests that meet the Medicare coverage criteria
and are reasonable and necessary to treat or diagnose
a patient. Therefore, the dentist or physician will
use prudent ordering practices.
In
requesting diagnostic procedures or tests, the dentist
or physician will make an independent medical necessity
decision with regard to each item ordered. A diagnosis
will be submitted for all tests ordered. Documentation
of findings and diagnoses will support the medical necessity
of the service.
The
dentist or physician understands that Medicare generally
does not cover routine screening tests and that organ
and disease related panels will be billed when all components
are medically necessary.
The
dentist or physician will order tests or services believed
to be appropriate for the treatment of the patient.
Advance
Beneficiary Notices (ABN) are used when there is a likelihood
that an ordered service will not be paid. The patient
will be notified, in writing, of the likelihood that
the service will not be paid, before the service is
provided. The ABN will only include those specific tests
which do not meet Medicare criteria for medical necessity.
Patients will never be offered blank ABNs to sign.
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Billing
All
claims for services submitted to Medicare or other health
benefits programs will correctly identify the services
ordered. Only those tests ordered by an authorized dentist
or physician, that are performed, and that meet Medicare's
or the health benefits program's criteria will be billed.
Intentional
or knowing upcoding (the selection of a code to maximize
reimbursement when such code is not the most appropriate
descriptor of the service offered) may result in immediate
termination. The dentist or physician must provide documentation
to support the CPT, HCPCS, and ICD-9-CM codes used based
on dental and medical findings and diagnoses.
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Reliance
on Standing Orders
Standing
orders will not be prohibited for an extended course
of treatment. However, when standing orders are utilized,
the dentist or physician should prescribe a fixed term
of validity, must renew the order upon its expiration
if continued treatment is indicated, and should confirm
in writing periodically the need for continued treatment.
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Compliance
with Applicable HHS Fraud Alerts
The
compliance officer and/or compliance committee will
review the Medicare Fraud Alerts. The officer/committee
will terminate the criticized conduct immediately, implement
corrective actions, and take reasonable actions to ensure
that future violations do not occur.
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Marketing
The
Dental or Medical Practice will promote only honest,
straightforward, fully informative and non-deceptive
marketing.
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Anti-Kick
Back/Inducements
The
Dental or Medical Practice will not participate in nor
condone the provision of inducements or receipt of kick-backs
to gain business or influence referrals. The dentist
or physician will consider the patient's interests in
offering referral for treatment, diagnostic, or service
options.
Any
employee involved in promoting or accepting kick-backs
or offering inducements may be terminated immediately.
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Retention
of Records/Documentation
The
Dental or Medical Practice will ensure that all records
required by federal and/or state law are created and
maintained. All records will maintained for a period
of no less than 7 years.
Documentation
of compliance efforts will include staff meeting minutes,
memoranda concerning compliance protocols, problems
identified and corrective actions taken, the results
of any investigations, and documentation supportive
of assessment findings, diagnoses, treatments, and plan
of care.
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2.
DESIGNATION OF A COMPLIANCE OFFICER AND/OR A COMPLIANCE
COMMITTEE
The
Dental or Medical Practice will designate a compliance
officer and/or compliance committee to serve as the
coordinator of all compliance activities.
Compliance
Officer
The
responsibilities of the compliance officer are:
•
overseeing and monitoring the implementation of the
compliance program.
•
reporting monthly/quarterly to the practice's responsible
body on the progress of implementation and assisting
the practice in establishing methods to improve efficiency
and quality of services and to reduce the vulnerability
to allegations of fraud, waste and abuse.
•
developing and distributing to all affected employees
all written compliance policies and procedures.
•
periodically revising the program in light of changes
in the needs of the organization and in the law, and
changes in policies and procedures of government and
private payor health plans.
•
developing, coordinating, and participating in a multifaceted
educational and training program that focuses on the
elements of the compliance program and seeks to ensure
that all employees are knowledgeable of , and comply
with, pertinent federal, state, and private payor
standards.
•
ensuring that all dentists and physicians are informed
of compliance program standards with respect to coding,
billing, documentation, and marketing, etc.
•
assisting in coordinating internal compliance review
and monitoring activities, including annual or p.r.n.
reviews of policies.
•
independently investigating and acting on matters
related to compliance, including the flexibility to
design and coordinate internal investigations.
•
developing policies and programs that encourage managers
and employees to report suspected fraud and other
improprieties without fear of retaliation.
The
compliance officer has the authority to review all documents
and other information relative to compliance activities,
including, but not limited to, requisition forms, billing
information, claims information, and records concerning
marketing efforts and arrangements with clients.
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Compliance
Committee
The
Dental or Medical Practice will designate a compliance
committee to advise the compliance officer and assist
in the implementation of the compliance program as needed.
The
functions of the compliance committee are:
•
analyzing the practice's regulatory environment, the
legal requirements with which it must comply, and
specific risk areas.
• assessing existing policies and procedures
that address risk areas for possible incorporation
into the compliance program.
• working within the practice's standards of
conduct and policies and procedures to promote compliance.
• recommending and monitoring the development
of internal systems and controls to implement standards,
policies and procedures as part of the daily operations.
• determining the appropriate strategy/approach
to promote compliance with the program and detection
of any potential problems or violations.
• developing a system to solicit, evaluate, and
respond to complaints and problems.
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3.
CONDUCTING EFFECTIVE TRAINING AND EDUCATION
The
Dental or Medical Practice requires all employees to
attend specific training upon hire and on an annual
and p.r.n. basis thereafter. This will include training
in federal and state statutes, regulations, program
requirements, policies of private payors, and corporate
ethics. The training will emphasize the practice's commitment
to compliance with these legal requirements and policies.
The
training programs will include sessions highlighting
the practice's compliance program, summaries of fraud
and abuse laws, discussions of coding requirements,
claim development, claim submission processes, and marketing
practices that reflect current legal and program standards.
The
compliance officer/committee member will document the
attendees, the subjects covered, and any materials distributed
at the training sessions.
Basic
training will include:
•
government and private payor reimbursement principles
• general prohibitions on paying or receiving
remuneration to induce referrals.
• proper translation of narrative diagnoses
• only billing for services ordered, performed,
and reported
• duty to report misconduct
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4.
DEVELOPING EFFECTIVE LINES OF COMMUNICATION
The
Dental or Medical Practice will protect whistleblowers
from retaliation.
The
Dental or Medical Practice will establish a procedure
so that employees may seek clarification from the compliance
officer/committee in the event of any confusion or questions
regarding a policy or procedure.
A
hot line/question box/mail box will be established so
that employees may anonymously consult with the officer/committee
with questions or report violations. A newsletter/bulletin
board/communication book/e-mail/written memorandum will
be used to communicate responses to anonymous inquiries
or reports, as well as to communicate other information
regarding compliance and compliance activities.
Any
potential problem or questionable practice which is
or is reasonably likely to be in violation of or inconsistent
with federal or state laws, rules, regulations, or directives
or Dental or Medical Practice rules or policies relative
to the delivery of health care services, or the billing
and collection of revenue derived from such services,
and any associated requirements regarding documentation,
coding, supervision, and other professional or business
practices, must be reported to the Compliance Officer/Committee.
Any
person who has reason to believe that a potential problem
or questionable practice is or may be in existence should
report the circumstance to the Compliance Officer/Committee.
Such reports may be made verbally or in writing, and
may be made on an anonymous basis.
The
compliance officer/committee will promptly document
and investigate matters reported that suggest substantial
violations of policies, regulations, statutes, or program
requirements to determine their veracity. The compliance
officer will maintain a log of such reports, including
the nature of the investigation and its results.
The
compliance officer/committee will work closely with
legal counsel, who can provide guidance regarding complex
legal and management issues.
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5.
DISCIPLINARY GUIDELINES
All
members of the Dental or Medical Practice will be held
accountable for failing to comply with applicable standards,
laws and procedures. Supervisors and/or managers will
be held accountable for the foreseeable compliance failures
of their subordinates.
The
supervisor or manager will be responsible for taking
appropriate disciplinary actions in the event an employee
fails to comply with applicable regulations or policies.
The disciplinary process for violations of compliance
programs will be administered according to practice
protocols (generally oral warning, written warning,
suspension without leave, leading to termination) depending
upon the seriousness of the violation. The compliance
officer/committee, as well as legal counsel, may be
consulted in determining the seriousness of the violation.
However, the compliance officer/committee should never
be involved in imposing discipline.
If
the deviation occurred due to legitimate, explainable
reasons, the compliance officer and supervisor/manager
may want to limit disciplinary action or take no action.
If the deviation occurred because of improper procedures,
misunderstanding of rules, including systemic problems,
the practice should take immediate actions to correct
the problem.
When
disciplinary action is warranted, it should be prompt
and imposed according to written standards of disciplinary
action.
Within
thirty (30) working days after receipt of an investigative
report, the supervisor and/or Chief Officer of the Dental
or Medical Practice shall determine the action to be
taken upon the matter. The action may include, without
limitation, one or more of the following:
•
Dismissal of the matter
• Verbal counseling
• Issuing a warning, a letter of admonition,
or a letter of reprimand
• Entering into and monitoring a corrective action
plan . The corrective action plan may include requirements
for individual or group remedial education and training,
consultation, proctoring, and/or concurrent review
• Reduction, suspension, or revocation of clinical
privileges
• Suspension or termination of employment
• Modification of assigned duties
• Reduction in the amount of salary compensation
The
Chief Officer shall have the authority to, at any time,
suspend summarily the involved provider's clinical privileges
or to summarily impose consultation, concurrent review,
proctoring, or other conditions or restrictions on the
assigned clinical duties of the involved provider in
order to reduce the substantial likelihood of violation
of standards of conduct.
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6.
AUDITING AND MONITORING
The
compliance officer/committee will conduct ongoing evaluations
of compliance processes involving thorough monitoring
and regular reporting to the officers of the Dental
or Medical Practice.
The
compliance officer/committee will develop audit tools
designed to address the practice's compliance with laws
governing kick-back arrangements, physician self-referral
prohibition, CPT, HCPCS and ICD-9-CM coding and billing,
claim development and submission, reimbursement, marketing,
reporting and record keeping. Internal audits will be
conducted on a quarterly/semi-annual/annual basis.
The
audits will inquire into compliance with specific rules
and policies that have been the focus of Medicare fiscal
intermediaries or carriers, as evidenced by the Medicare
Fraud Alerts, OIG audits and evaluations and publicly
announced law enforcement initiatives. Audits should
also reflect areas of concern that are specific to the
Dental or Medical Practice.
The
compliance officer/committee shall conduct exit interviews
of personnel in order to solicit information concerning
potential problems and questionable practices.
The
compliance officer/committee should be aware of patterns,
and trends in deviations identified by the audit that
may indicate a systemic problem.
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7.
RESPONDING TO DETECTED OFFENSES AND DEVELOPING CORRECTIVE
ACTION INITIATIVES
Violations
of the Dental or Medical Practice's compliance program,
failure to comply with applicable state or federal law,
and other requirements of government and private health
plans, and other types of misconduct may threaten the
Practice's status as a reliable, honest and trustworthy
provider capable of participating in federal health
care programs. Detected, but uncorrected misconduct
may seriously endanger the mission, reputation, and
legal status of the Practice. Consequently, upon reports
or reasonable indications of suspected noncompliance,
the compliance officer/committee must initiate an investigation
to determine whether a material violation of applicable
laws or requirements has occurred.
The
steps in the internal investigation may include interviews
and a review of relevant documentation. Records of the
investigation should contain documentation of the alleged
violation, a description of the investigative process,
copies of interview notes and key documents, a log of
witnesses interviewed and the documents reviewed, the
results of the investigation and the corrective actions
implemented.
If
an investigation of an alleged violation is undertaken,
and the compliance officer/committee believes the integrity
of the investigation may be hampered by the presence
of employees under investigation, those employees should
be removed from their current work activities pending
completion of that portion of the investigation. These
employees will be temporarily suspended with pay pending
the outcome of the investigation.
Additionally,
the compliance officer/committee must take appropriate
steps to secure or prevent the destruction of documents
or other evidence relevant to the investigation.
If
the results of the internal investigation identify a
problem, the response may be immediate referral to criminal
and/or civil law enforcement authorities, development
of a corrective action plan, a report to the government,
and submission of any overpayments, if applicable. If
potential fraud or violations of the False Claims Act
are involved, the Compliance Officer/Committee should
report the potential violation to the Office of the
Inspector General or the Department of Justice.
When
making a repayment for an overpayment, the Practice
should inform the payor of the following: (1) the refund
is being made pursuant to a voluntary compliance program;
(2) a description of the complete circumstances prompting
the overpayment; (3) the methodology by which the overpayment
was determined; (4) any claim-specific information used
to determine the overpayment; and (5) the amount of
the overpayment.
The
Chief Officer of the Dental or Medical Practice shall
have the authority and responsibility to direct repayment
to payors and the reporting of misconduct to enforcement
authorities as is determined, in consultation with legal
counsel, to be appropriate or required by applicable
laws and rules.
If
the Chief Office of the Dental or Medical Practice discovers
credible evidence of misconduct and has reason to believe
that the misconduct may violate criminal, civil or administrative
law, then the Compliance Officer/Committee will promptly
report the matter to the appropriate government authority
within a reasonable time frame, but not more than sixty
(60) days after determining that there is credible evidence
of a violation.
Office
of Inspector General Hotline: 1-800-HHS-TIPS (1-800-447-8477)
When
reporting misconduct to the government, the compliance
officer should provide all evidence relevant to the
potential violation of applicable federal or state laws
and the potential cost impact.
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8.
RESPONSE TO SPECIAL AGENTS VISIT FOR THE PURPOSE OF
INVESTIGATING ALLEGATIONS OF FRAUD AND ABUSE
In
the event special agents visit the Dental or Medical
Practice for the purpose of investigating fraud and
abuse allegations:
•
Request a copy of the search warrant and the affidavit
supporting it.
• Record names of all agents and agencies they
represent.
• Ask the agent to secure the premises and to
delay the search until counsel can be notified. If
he refuses, do not deny admission to the premises
which could be construed as obstruction of justice.
• Ask for a delay until all patients have been
seen.
• Accompany the agents during the search.
• Record beginning and ending times of the search,
items taken, areas searched, types of documents taken,
photographs taken, questions asked or comments made,
and requests made by agents.
• Identify items essential to daily operation
and request copies.
• If employees are interviewed, debrief them
after the search.
This plan has attempted to provide the foundation for
development of an effective and cost-efficient compliance
program.
This
Compliance Plan may be altered or amended in writing
only with the concurrence of the Chief Officer of the
Dental or Medical Practice. The adoption of this Compliance
Plan has been approved and authorized as designated
below effective this ______ day of ______________________,
1999.
DENTAL
OR MEDICAL PRACTICE
By:__________________________
Date:________
Source:
The Office of the Inspector General's Compliance Program
Guidance for Clinical Laboratories, August 1998. Sample
Compliance Plan. Page 12. 5/99
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For more information, please contact Cindy Stark at (800)
865-0650, or email cstark@teneregroup.com
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