A little-known provision of the Affordable Care Act requires medical practices of all sizes to develop their own compliance plans to reduce fraud and abuse, but we are still awaiting guidance as to what such programs should look like. According to Section 6401 of the ACA, new and existing practices will be required to have a formal compliance program in place before enrolling in Medicare and Medicaid, thus shifting the burden of fighting fraud and waste from the government onto doctors.
If there’s a problem with billing or an error or something was miscoded, the federal government can in the future point to these required compliance programs and say “You didn’t follow even your own required compliance program.” So this does shift the regulatory burden to the practice site from the government. Although the Department of Health and Human Services Office of Inspector General has yet to publish formal guidelines on how practices should craft their compliance programs, you might want to use the OIG’s 2000 guidance for voluntary programs as a model.
Physician practices, which have far fewer resources for compliance than hospitals, may find this mandatory requirement burdensome. Thus, high-priority items for practices should include training programs, self-audits, and drafting policies and procedures.