Spring 2011 issue of Horizons

Professional Services – continued

4. Conducting Appropriate Compliance Training

An integral part of any compliance program is the training of the provider’s employees. The method used to train employees may vary depending on the nature of the subject matter. In addition to the overall compliance training, specialized training (such as billing and coding) may be necessary for certain employees in the organization. 5. Responding to Detected Offenses and Developing Corrective Action Initiatives In a compliance program, providers need to develop indicators that will serve as “red flags” to alert management of potential noncompliance. Upon a report or a reasonable indication of noncompliance, the compliance officer will need to investigate the situation to make a clear determination of whether the facts support a noncompliance situation. If it is determined a noncompliance situation has occurred, the compliance officer would need to implement corrective action. Since a corrective action plan will vary depending on the nature of the noncompliance, the provider may want to seek legal counsel before any action plan is implemented. 6. Develop Open Lines of Communication In order reduce the risk of noncompliance and identify potential problems more quickly, Such indicators could be: • A significant change in denials • Increasing challenges in medical necessity • Unusual changes in the pattern of CPT and ICD-9/ICD-9-CM codes

interaction with the organization to be able to effectively understand the inner workings of the organization. The primary duties of the compliance officer are to: • Oversee the implementation of the compliance program • Establish methods to reduce an organization’s risk of fraud and abuse • Periodically revise the compliance program in light of changing requirements and standards from governmental and private payer health plans • Develop and coordinate training programs • Ensure that employees, physicians and contractors are checked against the HHS- OIG excluded provider lists • Investigate any reports or allegations of improper business practices

providers need to foster an environment in which employees can report potential noncompliance issues.

Raise Your Expectations

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