Spring 2011 issue of Horizons

patient’s interaction with the provider’s billing office by reducing errors that may occur during the billing process. There are seven basic elements that provide for an effective compliance program. The degree of implementation of these steps will vary based on the size and nature of the health care organization. 1. Reviewing and Monitoring Compliance An ongoing review process is important to the overall success of any compliance program. Periodic reviews can evaluate whether the providers are complying with current standards and practices, as well as assess the effectiveness of the overall compliance program. • A standards and procedures review ensures that procedures are current and complete based on current regulations and industry standards that providers rely on, such as changes in Current Procedural Terminology (CPT) and ICD-9-CM codes. • A claims submission review will review the bill and the medical record to ensure compliance with applicable coding, billing and documentation requirements. Specifically, the reviews will determine whether bills are accurately coded, documentation is completed accurately, and services provided are reasonable and necessary. There are two types of reviews that can be performed to assess the program:

As a result, the compliance documentation can be incorporated into existing standards. Since most of the associated risk to a provider centers around the billing process, providers need to have appropriate procedures in place to: • Promote accurate coding and billing • Ensure that only reasonable and necessary services are performed • Make certain that all documentation is timely, accurate and complete 3. Designation of a Compliance Officer Once procedures are established, providers need to ensure that procedures are kept current and that employees follow the procedures. To ensure ongoing compliance, providers should designate a compliance officer. Ideally, an organization would delegate one individual who is responsible for the oversight of the compliance program and for implementation of any necessary corrective action. Depending on the size of the organization, the compliance officer function may be outsourced. However, if this role is outsourced, the compliance officer would require sufficient

2. Establish Practice Standards and Procedures

Written procedures and standards are central components of a compliance program. These procedures establish the foundation for a strong internal control structure. Most providers already have “practice standards” that delineate policy standards related to patient care, personnel matters and other operational matters.

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