Establishing a Compliance Program
The steps you need to take to ensure your business is compliant.
By Tom Ambury, PT, CHC*
As we enter 2017, the need for private practices to have their own compliance program has become more apparent. Since 2011, we have seen the need for compliance grow. We have seen regulations increase, compliance laws enhanced at both the federal and state levels, and insurance policy changes regarding providing rehab or physical therapy services.
First, what are the potential advantages of having a compliance program?
- Helps to demonstrate due diligence in compliance matters: Private practice owners understood the need to perform due diligence when it came to opening a business. The owner took the time to understand the nature of his or her business and perhaps the rules associated with operating the business. Having a compliance program can be part of the due diligence process. A compliance program can help assure you are making your best efforts to comply with the multiple laws, rules, and guidances associated with operating a private practice.
- Helps to assure proper payment for services: All businesses need to be paid for the service or item the business is providing, and in private practice owners have the same requirement. Typically, a business is allowed to set the price for the service provided. Unfortunately, that is not the case in health care. The price for health care service is determined by the insurance provider. Typically therapists in private practice have an additional obligation to perform periodic audits to assure that claims are calculated and submitted correctly. Providing “clean claims” can have the added advantage of improving the cash flow of a practice by shortening the time it takes to process a claim. Medicare, for example, will process and pay a clean claim in three weeks from when the claim is submitted. A claim that has issues gets kicked back for correction and the process to get paid can take weeks. Claims submitted on paper also take longer to process and pay than electronically submitted claims. I’m not a knowledgeable business person, but it does seem to me the sooner I can get paid for my service the better.
- Helps to assure you get to keep the payment: All businesses occasionally need to make a refund to a dissatisfied customer. The fewer dissatisfied customers we have, the more of the payments we receive we get to keep. Unfortunately, with insurances that are federally funded, the potential for overpayments does more than create a dissatisfied customer, it can be a violation of the law with extensive fines and penalties. The amount of fines and penalties can put a practice out of business.
- Helps to assures you and your employees are on the same page when it comes to compliance matters: First let’s acknowledge that a business has a need to establish productivity standards. It is also equally important for therapists to understand that the services the therapist provides are to meet the needs of the patient. Having a compliance program can help assure staff of operating in the most ethical manner possible. Those of us who provide health care to a vulnerable population have a special obligation to meet the needs of the patient.
- Helps provide a recruiting advantage over other practices: I have talked with practice owners who tell me that having a compliance program can help provide a recruiting advantage over practices that may not have one. In some regions where it can be hard to recruit staff, this can be an advantage.
- Helps give employees a means to ask questions regarding compliance: It would be wonderful if health care compliance was black and white, but unfortunately much of compliance can be gray in terms of vaguely written rules and regulations. Having a compliance program can provide a means for an employee to ask questions about compliance as they come up.
How to get started?
Step 1: Make the decision to have a compliance program. Get started now because it takes time to get a program up and running and to become effective. To be honest, and this is just my personal opinion, because of all the auditing going on in 2017, the sooner you get started the better.
Step 2: Decide how you want to start. You can size your compliance program to the size of your practice. Obviously, the bigger your practice, the bigger and more robust your compliance program will be.
Step 3: Identify your risk areas. For most of us this is in documentation of services to support medical necessity and in submitting accurate claims for payment.
Step 4: Decide on a program. You can develop your own or you can purchase a compliance plan. Whichever plan you choose, make sure it contains the 7 elements of an effective compliance program as outlined by the Office of Inspector General (OIG).1
Step 5: Perhaps the most important area of compliance risk in private practice is having documentation in support of the services provided and correctly calculating charges submitted for payment. Therefore, I recommend that you start your program with auditing of your documentation and claims and with compliance training for you and your employees.
1 Compliance Program Guidance for Individual and Small Group Physician Practices. (65 Fed. Reg. 59434, October 5, 2000). Accessed February 2017.
Tom Ambury, PT, CHC, has been a physical therapist for over 25 years and is the president of PT Compliance Group. For additional information, he can be reached at firstname.lastname@example.org.*Tom Ambury has a vested interest in the subject of this article.