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June 22, 2012

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It's time to pay attention to "Compliance"

Overview and Regulatory Map for Healthcare Providers.

It all begins with the Inspector General Act of 1978 and the creation of Office of the Inspector General (OIG) and independent IG offices. The OIG website describes their mission as to “protect the integrity of Department of Health & Human Services (HHS) programs and program beneficiaries” by “ . . . combating fraud, waste and abuse and improving the efficiency of HHS programs.”

Though OIG watches over more than 300 other HHS programs, about 80% of OIG’s resources^[1] are currently dedicated to fighting waste and abuse in healthcare programs. Essentially, they find and help prosecute “crooks^[2]” that abuse the program, but they are also mandated to “promote economy, effectiveness and efficiency” in delivering benefits.^[3]

What does that have to do with my medical practice?

Before the Patient Protection and Affordable Care Act (ACA) became law, healthcare compliance programs were considered voluntary and a series of guidelines and other materials were developed to help virtually every link in the chain of healthcare providers except small group physicians develop effective compliance programs. The ACA changed three fundamental things about healthcare compliance:

Compliance program guidelines that were previously voluntary are now mandatory.
All healthcare providers (now including small group physicians and all other entities that provide Medicare, Medicaid, or CHIP program services) are required to develop an “effective” compliance program before they enroll or are paid for services under Medicare, Medicaid, or CHIP programs in the future.
Healthcare Compliance guidelines are now aligned with Chapter 8 of the Federal Sentencing Guidelines.

The sections of the ACA that apply specifically to developing a healthcare compliance program, relevant Federal Sentencing Guidelines and links to related government publications are listed here:

SEC. 6401	Provider Screening and other Enrollment Requirements under Medicare, Medicaid, and CHIP.	www.gpo.gov/fdsys/pkg/PLAW -111publ148/pdf/PLAW-111publ148.pdf
SEC. 6102	Accountability Requirements for Skilled Nursing Facilities and Nursing Facilities.	www.gpo.gov/fdsys/pkg/PLAW -111publ148/pdf/PLAW-111publ148.pdf
Under 18 U.S.C. §994(p)	Federal Sentencing Guidelines Chapter 8	www.ussc.gov/Guidelines/Organizational _Guidelines/guidelines_chapter_8.htm

When should I get started?
The short answer is “now.” Even if OIG and the HHS haven’t officially released the guidelines for your organization by the time you read this, there are already regulations requiring future compliance in place or being developed now as outlined below:

Nursing Facilities and Skilled Nursing Facilities under the ACA must have a program in place within 36 months of enactment of the ACA. Since the ACA was signed into law in March 2010, and barring any deadline extensions, that means you have until March 2013 to develop and implement a plan.^[4]
For any other healthcare provider that provides services under Medicare, Medicaid, or CHIP programs, the deadline is less clear. OIG and HHS are under deadlines to formally publish the core elements and an implementation timeline for small group practices and others covered by Section 6401 of the ACA.

What do I need to do?
First, click through the links and do some studying so you can find out just exactly how you are regulated and what’s expected of practitioners in your type of organization. Then, check out next month’s PBN Minute. It presents a quick guide for getting started on developing (or revising) an “effective” plan. And in the meantime, you can check out the OIG^[5] and HHS^[6] compliance program development guidelines, study and training materials, and other helps to get you going.

. . . And as always, PBN is here to help. If you have compliance questions or needs, contact PBN Business Development, 800.288.4901 or .

^{< sup>}^{^[1] Small Group Physicians and Other Health Care Providers: Now is the Time to Structure Your Mandatory Compliance Programs, Cynthia S. Marietta, J.D., LL.M. (Health Law) http://www.law.uh.edu/healthlaw/perspectives/2011/%28CM%29%20Compliance.pdf. Dr. Marietta cites the testimony of Gerald T. Roy (http://www.oig.hhs.gov/testimony/docs/2011/roy_testimony_04052011.pdf ) in her summary of how to structure a compliance program.

^[2] See the Inspector General story, a video describing the 25 year history of the OIG, here http://www.ignet.gov/psa/master_content.html

^[3] You can find out more about the OIG here: http://oig.hhs.gov/about-oig/about-us/index.asp

^[4] See § 1128I(B)(1) of Part A of Title XI of The Social Security Act as Amended by the ACA.

^[5] See the publication “Compliance Program Guidance for Individual and Small Group Physician Practices” available at http://oig.hhs.gov/authorities/docs/physician.pdf . Also see OIG Guidelines for your group here: http://oig.hhs.gov/compliance/compliance-guidance/index.asp Additional resource materials are available here: http://oig.hhs.gov/compliance/compliance-guidance/compliance-resource-material.asp.

^[6] A good place to start: “ Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians” at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Avoiding_Medicare_FandA_Physicians_FactSheet_905645.pdf}

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Meanwhile (again) . . .

We're hearing stories of practices that anticipate having to take out or extend their existing lines of credit. Why? To stay afloat as the extended discretionary period for enforcment of Version 5010 compliance ends . . . in just a bit more than a month from now.

That's the bad news (for some practices). The good news is that there are many free resources available from the CMS website and consultants (including PBN) who are here to help you get started.

More good news: HHS has proposed that the compliance date for ICD-10 be delayed 12 months to October 2014. This after several years of warnings that the date was a firm one. Though it's currnetly just a proposed change, I can't imagine that after reading comments on the proposed rule (the comments period closed May 17) that the date will be moved back to 2013.

Oh, and let's not forget that we'll need to readdress the SGR payment issue, soon (Congress only pushed the date out to October of this year).

What's a practice to do?

Give me a call to find out how we can help.

— Jud

Jud Neal, PBN President & CEO

Physicians Business Network

Visit us online at PBNMed.com .