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Many practitioners are unaware that the Patient Protection and Affordable Care Act of 2010 (ACA) mandates that all health care entities and providers participating in federal health care programs, including individual and small-group physician practices, implement effective compliance programs to prevent, detect and correct violations of federal health care laws and regulations.

Although ACA requires providers to implement a compliance program in order to continue to participate in Medicare and Medicaid, it leaves the timing and implementation of these requirements up to the Department of Health and Human Services (HHS).

To date HHS has not issued formal guidance on compliance program requirements under ACA for individual and small group practices, as it has for nursing facilities, Medicare Advantage Plans and Medicare prescription drug plans.

However, program requirements and implementation dates will likely be issued soon, and physician practices are strongly encouraged to develop and implement a compliance program in anticipation of HHS’s release of compliance guidance documents.

For guidance in developing an effective compliance program, practices can consult the guidance documents that were released by the HHS Office of the Inspector General (OIG) in 2010, when compliance programs were still voluntary. The 2010 guidance documents establish seven core elements that should be included in a compliance program for individual or small-group physician practices:

  • Conducting internal monitoring;
  • Implementing compliance and practice standards;
  • Designating a compliance officer or contact person;
  • Conducting appropriate training and education;
  • Responding appropriately to detected offenses and developing corrective action;
  • Developing open lines of communication; and
  • Enforcing disciplinary standards through well-publicized guidelines.

Benefits to strategically implementing a compliance program now, rather than waiting for HHS/OIG to set the mandated implementing timeline, include minimizing billing mistakes, optimizing proper payment of claims, reducing risks of audits, and avoiding conflicts with the self-referral and anti-kickback statutes.

For guidance in structuring a compliance program that fits your particular organizational structure and business needs, contact Bruce Lamb or any member of Gunster’s health care law practice.

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This publication is for general information only. It is not legal advice, and legal counsel should be contacted before any action is taken that might be influenced by this publication.

Gunster, Florida’s law firm for business, provides full-service legal counsel to leading organizations and individuals from its 11 offices statewide. Established in 1925, the firm has expanded, diversified and evolved, but always with a singular focus: Florida and its clients’ stake in it. A magnet for business-savvy attorneys who embrace collaboration for the greatest advantage of clients, Gunster’s growth has not been at the expense of personalized service but because of it. The firm serves clients from its offices in Fort Lauderdale, Jacksonville, Miami, Orlando, Palm Beach, Stuart, Tallahassee, Tampa, The Florida Keys, Vero Beach and its headquarters in West Palm Beach. With more than 170 attorneys and 200 committed support staff, Gunster is ranked among the National Law Journal’s list of the 350 largest law firms. More information about its practice areas, offices and insider’s view newsletters is available at www.gunster.com.

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