Compliance Programs for Healthcare Providers and Suppliers

Section 6401(a) of Patient Protection and Affordable Care Act established new requirements for providers and suppliers seeking to enroll in the federal or state healthcare programs. Specifically, it requires that as a condition of enrollment in Medicare, Medicaid or CHIP, a provider of medical or other items or services establish a compliance program that contains certain “core elements.” While the Centers for Medicare & Medicaid has yet to implement this requirement, many states have already passed their own laws requiring providers and suppliers of medical services to implement effective compliance programs when certain requirements are triggered.

Who is Required To Have Compliance Program in New York?

New York physicians, dentists, pharmacies and other healthcare providers or affiliates who provide care, services or supplies under the Medicaid program, and who claim or receive, or are reasonably expected to claim or receive, directly or indirectly, $500,000 or more in Medicaid funds (including from Managed Care Organizations) are required to implement and adopt effective compliance programs.

Other healthcare businesses required to have compliance plans, irrespective of the amount claimed or received, include:

  • hospitals
  • diagnostic treatment centers (DTCs)
  • home health agencies
  • providers of services for people with developmental disabilities
  • operators of mental health programs

Who is Required To Have Compliance Program in New Jersey?

New Jersey’s Office of the Medicaid Fraud Division has stated that it strongly encourages providers whose payments from the Medicaid program exceed $100,000 per year to implement a compliance program.

Compliance Programs Cover Many Important Areas of Healthcare Business Operations

For compliance program to be effective and to meet legal requirements set out by federal and state regulators, it must cover many important areas of healthcare business operations. This includes at least the following key areas:

  • Billing and coding; medical necessity
  • Staff reporting of compliance issues; non-retaliation policy
  • Provider/supplier contracting
  • Staff education and training
  • Personnel issues/conflict of interest
  • Internal Audits
  • Designation of a compliance officer

Our Compliance Services

An effective compliance plan must be tailored to the needs of each organization while meeting the state and federal legal requirements.  We regularly work with our clients to develop and implement effective compliance plans that meet these requirements.

To discuss your compliance plan needs or to schedule an initial consultation, please call our office at 732-637-9540.