Federal fraud enforcement and compliance planning

Any individual or entity providing health care services and submitting a claim for payment by the federal government must be alert to the potential for liability stemming from an inappropriately submitted claim. The federal government has the authority to investigate the claim's propriety and the authority to impose sanctions where an investigation finds fault with a claim, ranging from a possibly inadvertent mistake to a determination that the claim was fraudulently submitted. This document provides the skeleton for how physicians and other health care professionals can acknowledge and proactively address the federal fraud enforcement environment through the establishment of a compliance plan.

The existence of an effective compliance plan provides evidence that any mistakes were inadvertent, and this evidence would be considered in determining whether a medical practice or other health care entity has made reasonable efforts to avoid and detect misbehavior. A compliance plan also will identify under-coding and improve communications within a practice setting. An effective compliance plan should include the following seven elements:

1. A clear commitment to compliance. A compliance plan must ensure that everyone in the organization understands the obligation to comply with established and understood standards, and that the organization will take actions to uphold those standards.
   
   
2. Appointment of a trustworthy compliance officer with a high level of responsibility. The compliance officer will be considered to have the requisite authority if he or she is able to influence behavior and organizational practices.
   
   
3. Effective training and education programs. There must be a routine training and education process that addresses the role of everyone involved in the organization and makes participation in the compliance program understandable.
   
   
4. Auditing and monitoring. There must be a regular review of the organization's claim development and submission process, starting from the point where a service for a patient is initiated through the submission of a claim for payment. The monitoring process includes a methodology to facilitate employee reporting of suspected situations of fraud or abuse.
   
   
5. Communications. Organizations must maintain an effective communications process, including a "hotline" procedure to facilitate reporting of suspected violations.
   
   
6. Internal investigation and enforcement. Organizations must be able to conduct an appropriate investigation and take disciplinary actions.
   
   
7. Response to identified offenses and application of corrective action initiatives. On the identification of a compliance problem, organizations have a responsibility to take demonstrable corrective actions, including steps to prevent further similar offenses.

Documentation is a central component of an effective compliance plan. Accurate documentation on the operation of the compliance plan and of patient records is crucial. Medical record information provides the justification necessary to support claims payment. The medical record may be used to validate the site of the service, the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided, and that the services have been reported accurately.