ACA makes compliance programs mandatory for Medicare, Medicaid providers

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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