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“Is your organization prepared for greater accountability?”

Healthcare Compliance

Is your organization prepared for greater accountability?

While compliance programs have always been a good idea, they had not previously been mandated for most healthcare providers. With the passage of the Affordable Care Act, the reform law changes that by requiring a wide range of providers - from solo physician practices to the largest integrated health systems - to establish compliance and ethics programs to continue participating in the Medicare and Medicaid programs.

The OIG expects all health care organizations to be compliant with health care laws. This goes well beyond a paper document stuck in a file. It represents a functional, ongoing program with factors such as measuring effectiveness, proper training, review and update of policies and procedures. Your practice will be held accountable for new fraud and abuse risk areas that may arise as your organization becomes involved with new payment and delivery systems (such as medical homes, accountable care organizations, bundled payments, and value-based purchasing).

There are many areas of "compliance" for healthcare organizations, including:

  • Compliance with medical documentation
  • Compliance with billing and coding practices
  • Compliance with health and safety laws and regulations
  • Compliance with environmental laws and regulations
  • Compliance with human resources laws and regulations
  • Compliance with HIPAA laws and regulations


Lack of knowledge won't hold up in a federal audit.

The presence of some dishonest health care providers who exploit the health care system for illegal personal gain has created the need for laws that combat fraud and abuse and ensure appropriate quality medical care. Medicare and Medicaid have expanded audit contractor programs to squash fraud and waste. RAC/ZPIC or other contractors have been authorized by Medicare to come in to your office and request dozens, even hundreds of claims, with little notice and you must comply. Remember, even honest mistakes can trigger an audit.

Each day that passes without an effective compliance program increases your risk of staggering fines, penalties or even criminal liability if an auditor uncovers overpayments or alleged fraud. It is no longer a question of whether or not a practice will be audited by a third party, but when.

Compliance Program Guidance

OIG has developed a series of voluntary compliance program guidance documents directed at various segments of the health care industry, such as hospitals, nursing homes, third-party billers, and durable medical equipment suppliers, to encourage the development and use of internal controls to monitor adherence to statutes, regulations, and program requirements. The required components of mandatory compliance and ethics plans described in the Affordable Care Act are similar to the seven elements of compliance plans already spelled out by the OIG. Establishing and following a compliance program will help physicians avoid fraudulent activities and ensure that they are submitting true and accurate claims.

The following seven components provide a solid basis upon which a physician practice can create a voluntary compliance program:

  • Establishment of written compliance policies and procedures and distribution to employees.
  • Designation of a specific individual or individuals to monitor compliance (i.e., compliance officer and/or compliance committee).
  • Commitment to conducting formal training and education programs.
  • Development of internal system for communication of suspected compliance violations.
  • Commitment to auditing and monitoring to evaluate compliance and identify potential problematic areas.
  • Maintenance of disciplinary policies which are consistently enforced.
  • Development of process for investigation of suspected violations and reporting to the government and law enforcement authorities when necessary.


HealthCare Management Solutions offers a wide range of services, from helping clients to develop and implement compliance program policies and procedures to conducting coding and documentation audits, to completing operational assessments designed to identify high risk areas. We can assist you in the following areas:

  • Compliance Program Policies and Procedures
  • HIPAA Compliance in Healthcare
  • HIPAA Risk Assessment
  • How to Respond to an Audit
  • Risk-Based Coding
  • Red Flags Rule

Our company has been using HealthCare Management Solutions for over a year. We are a successful multi specialty practice that has recently incorporated neurology, intensivist, psychiatry, urology, general surgery, and neurosurgery. These additions to our practice occurred without an increase in denials and days in A/R.
Jill Hall - Director of Business Services @ Northeast Georgia Physicians Group
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HealthCare Management Solutions, LLC.
4452 Congressional Drive
Jacksonville, FL 32246