Compliance Program - What are the Requirements to Implement an Effective Program?
August 1st, 2017 - Christine Taxin
All sponsors are required to adopt and implement an effective compliance program, which must include measures to prevent, detect, and correct Part C or D program non-compliance as well as FWA.
The compliance program must, at a minimum, include the following core requirements:
1. Written Policies, Procedures, and Standards of Conduct;
2. Compliance Officer, Compliance Committee, and High-Level Oversight;
3. Effective Training and Education;
4. Effective Lines of Communication;
5. Well-Publicized Disciplinary Standards;
6. Effective System for Routine Monitoring and Identification of Compliance Risks; and
7. Procedures and System for Prompt Response to Compliance Issues.
In order to be effective, a sponsor’s compliance program must be fully implemented and should be tailored to each sponsor’s unique organization, operations, and circumstances. A compliance program will not be effective unless sponsors devote adequate resources to the program. Adequate resources include those that are sufficient to do the following:
1. Promote and enforce its Standards of Conduct;
2. Promote and enforce its compliance program;
3. Effectively train and educate its governing body members, employees, and FDRs;
4. Effectively establish lines of communication within itself and between itself and its FDRs;
5. Oversee FDR compliance with Medicare Part C and D requirements;
6. Establish and implement an effective system for routine auditing and monitoring; and
7. Identify and promptly respond to risks and findings.
CMS will consider a sponsor’s size, structure, business model, activities, the extent of its delegation of responsibilities to other entities, the breadth of its operation, and the risks it faces in evaluating whether adequate resources have been devoted to the compliance program.
###
Questions, comments?
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Latest articles: (any category)
Reporting Modifiers 76 and 77 with ConfidenceApril 18th, 2023 - Aimee WilcoxModifiers are used to indicate that a procedure has been altered by a specific circumstance, so you can imagine how often modifiers are reported when billing medical services. There are modifiers that should only be applied to Evaluation and Management (E/M) service codes and modifiers used only with procedure codes. Modifiers 76 and 77 are used to identify times when either the same provider or a different provider repeated the same service on the same day and misapplication of these modifiers can result in claim denials.
Five Documentation Habits Providers Can Use Implement to Improve Evaluation & Management (E/M) ScoringApril 11th, 2023 - Aimee WilcoxProvider education on E/M coding updates is vital to the success of any organization, but how do you whittle down the massive information into bite-sized pieces the providers can learn in just a few minutes? Check out the five steps we have identified to teach providers in just a few minutes that can significantly impact and improve coding outcomes.
Second Quarter 2023 Updates are Different This YearApril 6th, 2023 - Wyn StaheliThe second quarter of 2023 is NOT business as usual so it is important to pay attention to ensure that organizational processes and training take place to avoid mistakes. Not only have ICD-10-CM coding updates been added to the usual code set updates (e.g., CPT, HCPCS, ICD-10-PCS), but the end of the COVID-19 Public Health Emergency will bring about changes that will also take place during the quarter (but not on April 1, 2023.
7 Measures Developed by the HHS Office of Inspector General (OIG) to Identify Potential Telehealth FraudMarch 28th, 2023 - Aimee WilcoxA recent review of telehealth services reported in Medicare claims data during the pandemic where these seven measures for identifying suspected fraud, waste, and abuse were applied, revealed more than a thousand Medicare providers potentially committed fraud during this period. What are the measures the OIG applied during their review, and how will that impact future telehealth guidelines moving forward?
MUEs and Bilateral IndicatorsMarch 23rd, 2023 - Chris WoolstenhulmeMUEs are used by Medicare to help reduce improper payments for Part B claims. This article will address the use of the National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs) and how they are used by CMS.
It is True the COVID-19 PHE is ExpiringMarch 16th, 2023 - Raquel ShumwayThe COVID-19 PHE is Expiring, according to HHS. What is changing and what is staying the same? Make sure you understand how it will affect your practice and your patients.
Billing Process FlowchartMarch 2nd, 2023 - The Billing Process Flowchart (see Figure 1.1) helps outline the decision process for maintaining an effective billing process. This is only a suggested work plan and is used for demonstration purposes to illustrate areas which may need more attention in your practice’s policies and...
