Initial steps to implementing a compliance plan
A summary of the steps to be taken to implement a compliance plan ("Plan") and to commence the ASC's compliance efforts are as follows:
- Provide a draft of a compliance plan;
- Review the entire Plan in detail;
- Discuss the Plan and safe harbors with the board of managers of the ASC;
- Edit and revise the Plan;
- Adopt the Plan at the board level;
- Appoint a chief compliance officer;
- Host an initial all-staff meeting to acknowledge the Plan and obtain employees' acknowledgments of their receipt and review of the Plan; and
- Present the Plan to owners and distribute a copy of the Plan.
Key annual and periodic efforts
As a center adopts the Plan and takes the first steps toward implementing the Plan, there are a handful of specific focal points that can be used as guideposts for your compliance efforts. The intent of these guideposts is to provide a method to ensure significantly enhanced compliance efforts on a reasonably practical basis. The guideposts include:
1. All staff and physician compliance meetings. The ASC should periodically (at least annually) host a one to two hour conference or discussion whereby health care regulatory concerns and issues are explained to all staff and all physicians. These should include a discussion of the impact of the Stark Act, the Medicare/Medicaid Fraud and Abuse Statute, reimbursement, fee-splitting, HIPAA and other issues of concern to the organization, its employees and physicians. These meetings may be handled in person and may be supplemented by periodic teleconferences.
2. Owner and board of managers meetings. A discussion of compliance initiatives should be included on the agenda for all regular meetings of owners and the board of managers.
3. Billing and coding review and audit. At least annually, an outside firm should be utilized to perform a sample review of the ASC's billing and coding efforts to ensure compliance with billing and coding rules. Internally, this effort should be supplemented a number of times per year. Billing and coding remains a key focus of investigative efforts. Thus, a disproportionate amount of attention should be spent on reviewing and improving billing and coding efforts.
4. Employee complaints. The ASC should establish methods whereby employees can report misconduct or healthcare regulatory concerns. Here, any reporting employee should be assured that his or her reporting will have no negative impact upon the employee's career with the ASC. In fact, such actions should be encouraged and applauded.
5. Seminars. Key leaders of the ASC, both on an overall basis and as to the various departments, should be encouraged to attend one to two compliance related seminars every year. This is intended to inform and to educate such persons as to compliance issues. The chief compliance officer should make it a key point of his or her efforts to ensure that such persons continue to gain additional knowledge on compliance related issues.
6. Compliance plan. At least annually, the Plan should be reviewed as a whole by counsel and by key executives to ensure that the Plan is appropriate for the organization and to update the Plan to take into account changes in the regulatory environment.
7. Compliance manual and periodic updates. Periodically (ideally annually), specific literature in the form of articles or summaries should be provided to employees throughout the organization to continue to raise the level of consciousness as to compliance issues.
8. Wall certificates. Posted notices to employees should be placed in appropriate places informing the employees of the ASC about the Plan and the need to report compliance issues to the ASC.
9. HIPAA privacy standards. The HIPAA privacy standards require the ASC to appoint a privacy official and to adopt a separate HIPAA compliance plan.
10. Background checks on employees and contractors. The ASC should ensure that all employees have not previously been excluded from Medicare or Medicaid.
Mr. Becker (sbecker@mcguirewoods.com), Ms. Szabad (mszabad@mcguirewoods.com) and Ms. Walsh (awalsh@mcguirewoods.com) are attorneys for McGuireWoods.