May 11, 2010

Components of Compliance:

1. Auditing and Monitoring

Claims Submission Audit:

  • Baseline Audit
  • Yearly Follow Up Audits (OIG recommends 5 or more charts from each Federal payor or five to 10 records for each physician.

Billing and Reimbursement:

  • Written Billing and Reimbursement Policies.
  • Written Standards for Documentation of Patient Records.
  • Written Balance Billing Policies.
  • Written Waiver of Copay and Deductible Policy.
  • Written Policy for Internal and/or External Audits – both Prospective and Retrospective.
  • Written Policies to Respond to Allegations of Non-Compliance.
  • Written Policies to Address Violations.
  • Written Policies to Address Inquiries and Outcomes To Inquiries to National Practitioner Data Bank, Cumulative Sanction Report and GAO Debarred Contractors Listing.

2. Standards & Procedures

Periodic review of standards and procedures to ensure they are current and complete.  Example – updating fee schedule, encounter form to reflect latest changes in CPT and ICD-9 updates

3. Designate a Compliance Officer

4. Conduct Training & Education

5. Respond to Detected Offenses

6. Open lines of communication

7. Enforcing Disciplinary Standards

8. Other Areas of Compliance:

Employment ComplianceWritten Personnel Policy Manual.

  • Written Policy on Sexual Harassment.
  • Written Policy on Hostile Work Environment
  • Written Policy on Leave of Absence/Military Leave.
  • Written Policy on Release of Employee Information, Including Storage of Medical Records.
  • Written Policy on Patient and Practice Confidentiality.
  • Written Policy on Signed Acknowledgement of Receipt of Personnel Policy.
  • Written Policy Regarding Payment of Overtime Compensation and Knowing It Is Correct.
  • Written Policy Regarding Compliance with ADA & FMLA (knowing when it applies to you).

ERISA Compliance

  • Identifying the type of retirement plan or welfare benefit plan and knowing what ERISA rules apply.
  • Making certain plan documents are up to date.
  • Written policy requiring all qualified employees receive a Summary Plan Description within 90 days of becoming a participant.
  • Written policy and actual practice of distributing Summary Annual Reports and Plan Participant Statements in a timely manner.
  • Determine if appropriate fiduciary bond is in place.

CLIA Compliance

  • Reviewing in-office clinical laboratory setup.
  • Written policies & procedures regarding quality control.
  • Written current Laboratory Procedures Manual.
  • Written policies concerning annual training and retention of records.


  • Written policies regarding confidentiality of patient information.
  • Reviewing office set-up for inadvertent breaches of confidentiality.
  • Written policies regarding fax requests for information.
  • Formalized process for release of information, including what information requires specific authorization to disclose.
  • Keeping patient information readily available while protecting patient rights.


  • Reviewing all policies with contractors, vendors, etc. to ensure no potential exists for anti-kickback violations.
  • Reviewing  “Designated Health Services” to determine if liability exists.
  • Reviewing “Joint Venture Arrangements” for liability.

Previous post:

Next post: