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The federal Department of Justice, the Office of Inspector General (OIG) at the Department of Health and Human Service, state Medicaid fraud control units, and other enforcement agencies have brought enforcement actions against various physician practices – even small practices – over the course of the past twenty years.*)
The institutional risks of noncompliance have grown since 1995 from relatively non-adversarial audits and occasional return of payments to formal investigations, prosecution under the False Claims Act, and whistleblower action.
The personal risks of noncompliance have changed too from money return to exclusion from government programs and loss of practice license. Administrators can be barred from working in the healthcare industry and clinicians, managers, corporate directors, even outside consultants can be jailed for healthcare fraud and abuse.
The federal government strongly encourages health compliance programs and promotes voluntary compliance and self-policing in a variety of ways. For instance, in the case of Medicare and the OIG, the existence of a corporate compliance program influences the approach to a violation of a federal requirement in terms of an innocent mistake or a fraudulent act. The existence of a corporate compliance program may determine whether the matter can be routinely handled as an overpayment by the payer or it must be investigated by the OIG, or even referred to the Department of Justice to be pursued as a civil infraction or as a criminal matter.
Ten questions to help deciding if you need a compliance management program. You should consider implementing it if you answer affirmatively to most of the following questions:
- Do you currently face regulatory problems?
- Have you been a target for audits or investigations in the past?
- Are your regulatory obligations changing and/or complex?
- Do you frequently disagree with your group members about the importance of compliance?
- Do you experience poor employee morale and frequent turnover, especially among billing staff?
- Do you have complex business/investment and referral relationships with other providers?
- Do you routinely practice aggressive coding?
- Do you rapidly expand into ancillary service areas?
- Do you practice in a geographic area where other practices have been frequently audited?
- Do you offer a very broad range of services relatively to its size?
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* Much of the material for this section of the website follows “Understanding Compliance: A Program Guide Based on the OIG 2000 Guidance,” by R. Saner, M. Spindel, A. Nordeng, Powers, Pyles, Sutter & Verville, P.C., MGMA, 2000
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