OIG
Effective Compliance Program- The Seven Basic Elements
by A. Maureen Hanna
OIG
Effective Compliance Program-
The Seven Basic Elements
by A. Maureen Hanna
Element # 6 - Conducting internal monitoring and auditing
An ongoing evaluation process is critical to a successful compliance program. The OIG believes an effective compliance program should incorporate thorough monitoring of its implementation and regular reporting to DMEPOS supplier's corporate officers.
Compliance reports created by this ongoing monitoring, including reports of suspected noncompliance, should be maintained by the compliance officer and shared with the DMEPOS supplier's corporate officers and with the compliance committee.
One effective tool to promote
and ensure compliance is the performance of regular, periodic
compliance audits by internal or external auditors who have expertise
in Federal and State health care statutes, rules, regulations,
as well as Federal, State and private payor health care program
requirements. The audits should focus on the different DMEPOS
supplier's departments, including external relationships with
third-party contractors. At minimum these audits should be designed
to address the DMEPOS supplier's compliance with the laws governing:
Kickback arrangements;
Self-referral prohibition
Pricing;
Contracts;
Claim development and submission;
Reimbursement;
Sales and marketing.
Monitoring techniques may include sampling protocols that permit the compliance officer to identify and review variations from an established baseline. If a deviation was caused by improper procedures, misunderstanding of rules, including fraud and systemic problems; the DMEPOS supplier should take prompt steps to correct the problem. Overpayments discovered as a result of such deviations should be returned promptly to the affected payor.
An effective compliance program
should include periodic (at least annual) reviews whether the
program's compliance elements have been satisfied. As part of
the review process, the compliance officer or reviewers should
consider:
Testing staff on their
knowledge of rules and/or regulations;
On-site visits to all facilities;
Ongoing risk analysis and vulnerability assessments
Assessments of existing
relationships with physicians and other potential referral sources;
Unannounced audits;
Examination of compliance
logs;
Checking of personnel records for individuals have been reprimanded;
Interviews with personnel;
Questionnaires to solicit impressions of the DMEPOS supplierís
employees;
Interviews with referral
sources; and
Review of medical necessity documentation.
 |
 |
 |
 |
 |
 |
 |
 |