• Electronic Medical Records (EMR)
• Scheduler with Eligibility Test
• Compliance Management
  + Core Elements
  + Regulatory Risks
  + Auditing and Monitoring
  + Documentation Guidelines
  + Audit Exposure Evaluation
• Data Entry and Payment Posting
+ Charge Entry
• Superbill Interface
• Variety of Claim Entry Formats
• Fax
+ Demographic Data Entry

• Coding
  + Coding Consistency
  + Discovery of Undercoding
• Claim Submission to Payers
• Patient Invoicing
• Follow Up
  
+ Discovery of Underpayment

• Transparency, Analysis and Reporting
• Quality Control
  + Billing Process
  • Payment Distributions
  • Days in A/R
  + Claim Validation
  + Patient Eligibility Testing
  
• Data Center
  

Generally, compliance programs programs are not required by law. Unless a group has been ordered to implement such a plan by a court of law or has agreed to a compliance plan as part of a settlement agreement, each group is free to decide about development of such a program and its extent.

The Federal Sentencing Guidelines are designed to ensure consistency in criminal sentencing by federal judges for federal crimes. These guidelines describe seven elements that must be included in the program for it to be counted as an effective compliance program. If a compliance program was in place, and deemed to be effective, the sentence will be less harsh. Both the existence and the efficacy of a compliance program are necessary to receive a less harsh sentencing.

The Sentencing Guidelines define an “effective program to prevent and detect violations of law” as a program that has been reasonably designed, implemented, and enforced so that it generally will be effective in preventing and detecting criminal conduct and will include at least the following seven elements:

1. Establishment of compliance rules and procedures that are reasonably capable of reducing the prospect of wrongdoing;
2. The assignment of high-level personnel to oversee the compliance effort;
3. The use of due care to prevent delegation of substantial discretionary authority to individuals whom the company knows or should know have a propensity to engage in illegal activities;
4. The effective communication of the standards and procedures of the program to all employees by either training programs or dissemination of information;
5. Taking reasonable steps to achieve compliance with the standards, e.g., by using monitoring and auditing systems reasonably calculated to detect criminal conduct and the establishment and publicizing of a reporting system that employees and other agents can use to report criminal conduct without fear of retribution;
6. Consistent enforcement of the standards through disciplinary mechanisms, including discipline of individuals responsible for the failure to detect and offense; and
7. Appropriate response to offences detected including the implementation of any modifications to the program necessary to prevent future offences of the same kind.

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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