Making Compliance Accessible to Your Practice

Open door with light shining through
By Kelly Grahovac*

The Affordable Care Act (ACA) mandates that any provider or supplier enrolled in Medicare, Medicaid, or Children’s Health Insurance Program must implement a compliance program.1

To date, CMS has only extended this compliance requirement to Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs) in order to receive payment under the Medicare and Medicaid programs, but times are changing.

Long before the enactment of the ACA, the Office of the Inspector General (OIG) developed seven elements of an effective compliance program that was published to the Federal Register. The OIG has developed compliance program guidance documents for multiple provider types, including Hospitals, Home Health Agencies, DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies), Nursing Facilities, Ambulance Suppliers, and Individual and Small Group Physician Practices. The development and issuance of this voluntary compliance program guidance serves as a way to assist providers in preventing the submission of erroneous claims or engaging in unlawful conduct involving the federal health care programs.

It is important to note, that just because a specific provider type does not have a dedicated compliance program guidance document, it does not mean that your industry is in less need of a compliance program. In fact, the OIG Compliance Program for Individual and Small Group Physician Practices2 states that “Much of this guidance can also apply to other independent practitioners, such as psychologists, physical therapists, speech language pathologists, and occupational therapists.”

An effective compliance program can be established based on the seven elements outlined in the OIG guidance. These seven elements are:

  1. Conducting internal monitoring and auditing
  2. Implementing compliance and practice standards
  3. Designating a compliance officer or contact
  4. Conducting appropriate training and education
  5. Responding appropriately to detected offenses and developing corrective action
  6. Developing open lines of communication
  7. Enforcing disciplinary standards through well-publicized guidelines

What is unique to the guidance issued to individual and small group practices is that the OIG emphasizes that the guidance should not be viewed as mandatory or as an all-inclusive plan for a compliance program. Rather, the document is intended to present guidance to assist practices that voluntarily choose to develop a compliance program. This is largely based on the financial and staffing resource constraints faced by individual and small practices. As a therapy practice owner, this is great news, as it makes a compliance program even more accessible.

Developing a voluntary compliance program not only strengthens your efforts to prevent and reduce improper conduct, but in some instances, can help to streamline business operations. Further, all health care providers have a duty to ensure that the claims submitted to federal health care programs are true and accurate. The development and application of a voluntary compliance program helps to achieve this goal. From a business perspective, a well-designed compliance program can speed and optimize proper payment of claims, minimize billing mistakes, and reduce your chances of being audited.

Establishing a compliance program can be a multitiered process. Initial development of the compliance program should be focused on potential risk areas to your practice that have been problematic in the past, such as coding and billing. Within this area, the practice should review its claims denial history or claims that have resulted in repeated overpayments, and identify and correct the most frequent sources of those denials or overpayments. A review of claim denials will not only help you to better scrutinize a significant risk area but may also improve cash flow by submitting correct claims that will be paid the first time they are submitted. Auditing and monitoring your claims, and developing an appropriate response program if a problem is identified, is a great first step in developing your compliance program.

After you have completed your audit and identified any risk areas, the next step is to develop a method for dealing with or responding to the risk. A response plan is easily laid out through written standards and procedures. In fact, your therapy practice may already have some of these in place, by way of practice policy statements regarding patient care, personnel matters, and practice standards and procedures on complying with federal and state law.

Designating a compliance officer or compliance contact for your organization is also essential. It is likely that this person will have other tasks, in addition to compliance. However, the goal is to have a person or persons who can reasonably address compliance concerns and provide appropriate responses to any identified risks. Ideally, this individual would periodically conduct audits and monitor the results, review and revise the practice’s compliance program, conduct compliance training, and be the “go-to” for employees to report any compliance concerns. Having open lines of communication is crucial to ensure your organization operates compliantly. Staff should know who to go to if they believe a potential compliance violation has occurred. More importantly, they should feel that this person will investigate the reported issue appropriately and not fear retribution for reporting it.

As previously mentioned, compliance training is an essential aspect of your compliance program. At minimum, this should be conducted annually and should include training on compliance in coding and billing related to state and federal regulations. Training should be documented, to include employee signature/recognition and date completed. The goal in training is to ensure that your employees understand that compliance is a condition of employment. Your staff should be familiar with your written policies and procedures and understand that violating them will result in disciplinary actions. Translating the commitment to compliance to your staff also involves having an appropriate response plan for identified offenses. Think of this as your corrective action plan. Whether an issue is identified during a claims audit, or an employee notifies you of a widespread billing error, the goal is to know what to do with the information. These steps should also be outlined in your compliance manual.

Developing your compliance program does not require large amounts of time or resources. Using the steps outlined earlier, and detailed in the OIG’s compliance guidance, your practice can develop its own compliance program. In fact, you may already have many of these recommendations in place. A compliance program can prevent fraudulent or erroneous conduct and, in some cases, streamline and improve business operations.

Reimbursement compliance is an important piece in today’s health care industry. This commitment to compliance extends beyond state and federal payers. In fact, a practice should focus compliance efforts on their own payer base, using their largest payer sources policies for billing and reimbursement guidance. Audit focus extends beyond Medicare and Medicaid plans, with commercial plans increasing their audit efforts. Ensuring compliance on a broader scale to include your large payer plans can further protect your practice should a post-payment audit occur.

Last, when considering the push for compliance, consider your patients’ partners in care. Affordable care organizations are including therapy as part of their care link. Having an active compliance program makes you an attractive partner in caring for patients. Outside of an ACO, insurance plans evaluate your potential to become part of their network. Proof of compliance ensures that you understand the billing and coverage requirements and will adhere to them, thus making you an attractive partner.

At this time, mandatory compliance programs for most providers as a condition for enrollment in federal payer programs is largely unenforced. However, when you consider the benefits that a compliance program brings to your organization, putting one into place is a rewarding advantage. Having a commitment to compliance extends beyond your practice to your patients and their health care partners. If you are interested in implementing a compliance program, check out the OIG website, or reach out to a third party for assistance.


1Title VI, Part III, Subtitle E, Section 6401

2 Accessed April 1, 2019.

Kelly Grahovac

Kelly Grahovac is a senior consultant at Van Helm Group in Atlanta, Georgia. She counsels health care providers as they navigate complex regulatory issues related to Medicare and Medicaid. She can be reached at

*This author has a professional affiliation with this subject.

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