David S. Barmak Health Care Law Blog on Lawyers.com

Corporate
Compliance Program for Medicaid Providers: Required by New York State and In
Near Future Federal Government

Compliance
programs encourage employees to report potential problems and permit the
provider to conduct an internal investigation and take corrective action. Thus,
the successful compliance program should increase the likelihood of preventing,
identifying, and correcting unlawful, abusive or wasteful conduct at an early
stage, minimizing financial loss to the government, to taxpayers, and to the
provider.

Compliance
programs need to encompass billings, payments, medical necessity, quality of
care, governance, credentialing and other risk areas that a provider, with due
diligence, identifies. Specifically, any compliance plan should include the
following elements:

1. Designation
   of a chief compliance officer responsible for the day-to-day operation of the
   compliance program; this employee should report directly to the provider's chief
   executive and periodically report to the governing body (if such a body exists)
   on the activities of the compliance program;
   
2. Training
   and education of all affected employees and persons associated with the
   provider, including executives and governing body members, on compliance issues,
   expectations, and the operation of the compliance program; such training should
   occur periodically and should be made a part of the orientation of new employees
   and governing body members;
   
3. A
   communication process, such as a hotline, accessible to all employees, outside
   vendors, governing body members, patients or other users of the provider's
   services, for the reporting of compliance issues; the lines of communication
   should allow for anonymous and good faith reporting of potential compliance
   issues as they are identified;
   
4. Disciplinary
   policies and standards that are distributed to all employees, which are fairly,
   evenly, and firmly applied, and encourage good faith participation in the
   compliance process, including policies that articulate expectations for
   reporting compliance issues and assist in their resolution and outline sanctions
   for:
   
   
   
   1. failing
      to report suspected problems;
      
   2. engaging
      in non-compliant behavior;
      
   3. encouraging,
      directing, facilitating or permitting either actively or passively non-compliant
      behavior.
   
   
5. A
   system for routine identification of compliance risk areas specific to the
   particular provider, for self-evaluation of such risks areas, including but not
   limited to internal audits and as appropriate, external audits, and for
   evaluation of potential or actual non-compliance as a result of such
   self-evaluations and audits, credentialing of providers and persons associated
   with providers, reporting, governance, and quality of care to beneficiaries.
   
6. A
   system for responding to compliance issues as they are raised; for investigating
   potential compliance problems; responding to compliance problems as identified
   in the course of self-evaluations, external evaluations and audits, correcting
   such problems promptly and thoroughly and implementing procedures, policies and
   systems as necessary to reduce the potential for recurrence; identifying and
   reporting compliance issues to the Office of the Medicaid Inspector General; and
   refunding overpayments.

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