Why is Compliance the new buzzword in health care? Most industries have monitored their own compliance with safety and environmental laws and regulations for many years. Now the word is being used daily in the health care industry with an added meaning. It has come to mean not only compliance with safety and environmental laws, but more especially with billing and anti-kickback laws.

Trends in Prosecutions for Healthcare Fraud and Abuse

The government calls it atypical white collar crime. Healthcare providers believe they are making honest mistakes. Whatever it is called, there is no doubt that prosecution for healthcare fraud and abuse is on the rise. New laws including the Health Insurance Portability and Accountability Act (HIPAA) have raised the risks. Healthcare providers are subject to penalties ranging from criminal prosecution through civil monetary penalties and exclusions from Medicare programs. In 1997, U.S. attorneys prosecuted 552 criminal cases of health care fraud. Both civil and criminal health care prosecutions netted the government a record $1.2 billion in judgments, settlements and fines.

Some recent convictions

All areas of healthcare have been effected by this move to prevent fraud and kickback. Some areas of healthcare that have had recent convictions for fraud or kickback are ambulance services, billing firms, hospitals, clinics, suppliers, group homes, home health services, nursing homes, rehab services, and physicians.

What can an honest healthcare provider to remain compliant with laws and regulations?

Are most healthcare providers frauds and criminals? The answer, of course, is no, but even honest providers makes mistakes. Currently a small physician group in the northwest that billed for $30,000 worth of services under the wrong provider number may face nearly two million dollars in fines. A misunderstanding of the complex Medicare and Medicaid billing regulations caused that problem. How does the innocent provider insure he does not become the victim of an over-enthusiastic auditor or whistle blower? The key is to initiate a voluntary compliance program.

The purpose of compliance programs is to guide a facility's governing body, managers, other employees, physicians, and other health care professionals in compliance with all laws and regulations pertaining to their facility. But compliance is more than a defensive initiative for health care institutions. Since a compliance program is directed at insuring an organization complies with laws and regulations, it can also dramatically improve other functions.

How can a healthcare provider begin to build a compliance program?

1. Take a top-down approach, with buy-in at all levels, led by senior management. Begin with a written statement instituting a compliance plan from the Board of Directors or Corporate Officers.

2. Complete a baseline audit to determine your risks and needs.

3. Select a Compliance Committee to oversee the process and a Compliance Officer to direct the process.

4. Write a Compliance Plan and a Code of Ethical Conduct based on problems uncovered during the baseline audit, and assure the program includes all of the federal guidelines for completing a compliance program

4. Fully integrate any compliance efforts into your overall organizational control structure and control environment.

5. Make the process continuing and evolving. Monitoring, reporting, feedback, and follow-up should be ongoing.