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Why Individual and Small Group Physician Practices Need A Compliance Program

More than a decade ago the Office of the Inspector General (OIG) issued Compliance Program Guidelines for Individual And Small Group Physician Practices, which are a set of voluntary guidelines for a small group physician practice or an individual practitioner. Nowadays, when federal and state governments are increasingly interested in cutting fraud, waste and abuse from their healthcare programs, they are aggressively looking to audit and investigate healthcare providers’ services. It therefore behooves providers to demonstrate to auditing and investigating agencies a practice’s adherence to applicable statutes, regulations and other program requirements through the creation and implementation of a written compliance plan.

According to OIG, “physician practices may view the implementation of voluntary compliance program as comparable to a form of preventive medicine for the practice,” so that “[p]ractices that embrace the active application of compliance principles in their practice culture and put efforts towards compliance on a continued basis can help to prevent problems form occurring in the future.” In other words, having a compliance protocol for your practice and following it, can add the much needed good-will when government representatives come knocking at your door.

The guidelines recommend seven components that should form the backbone of a physician’s compliance program.  However, the OIG recognizes that full implementation of all components may not be feasible for all physician practices and that some  physician practices may never fully implement all of the components. “[T]his guidance for physicians does not suggest that physician practices implement all seven components of a full scale compliance program. Instead, the guidance emphasizes a step-by-step approach to follow in developing and implementing a voluntary compliance program.”

The seven components of the OIG’s compliance program guidelines are:

  • conducting internal monitoring and auditing through the performance of periodic audits
  • implementing compliance and practice standards through the development of written standards and procedures
  • designating a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards
  • conducting appropriate training and education on practice standards and procedures
  • responding appropriately to detected violations through the investigations of allegations and the disclosure of incidents to appropriate government entities
  • developing open lines of communications, such as 1) discussions at staff meetings regarding how to avoid erroneous or fraudulent conduct and 2) community bulletin boards, to keep practice employees updated regarding compliance activities; and
  • enforcing disciplinary standards through well publicized guidelines

As a first step, the OIG advises physician practices begin by adopting only those components which, based on a practice’s specific history with billing problems and other compliance issues, are most likely to provide an identifiable benefit. Prior to any disclosures to government entities, providers should seek the advice of counsel.