Efficient in-house program crucial to success
When it comes to healthcare and compliance, providers have more concerns than ever before and many are looking at the overall effectiveness of their compliance program.
Alice V. Harris, a partner at Nelson Mullins Riley & Scarborough in Columbia, S.C. and member of the Health Care Compliance Association, said that one of the central compliance issues that healthcare organizations face is gauging how effective - if at all - their compliance program is in dealing with the numerous and complex issues they confront.
"The focus was once about having a compliance program, which meant that you had one in place and made sure you met the elements that the (U.S. Office of Inspector General) had specified, but the industry has changed to gauging whether that program is effective in creating and maintaining a compliant environment," said Harris. "So there's talk going on in how you gauge that effectiveness and the OIG has issued guidance on how to walk through and gauge your effectiveness."
Having an effective compliance program allows healthcare organizations to be able to deal with responding to the several types of auditor requests that occur, which can often be a struggle for many providers. Harris said in addition to handling Medicare and Medicaid Recovery Audit Contractors (RACs), there are numerous federal and state program integrity contractors, and non-federal auditors.
"Having someone to receive the requests, to respond to them, to understand if there are overpayments or not, to handle the appeals and coordinate responses - it's really a giant project for many providers right now," she said.
Kim Looney, a partner at Waller, in Nashville, Tenn., also said it's important for healthcare organizations to have compliance programs that run efficiently.
"It's not just about having a plan, but it's about having an effective plan and doing what you say you're going to do," said Looney.
One area where industry experts say it's particularly important to have an efficient in-house program established is in the case of overpayment.
Changes with the False Claims Act regarding making sure overpayments are processed in a timely manner are a huge concern for many healthcare organizations, said Jim Hoover, a partner at Burr & Forman Health Care Practice Group in Birmingham, Ala.
"With overpayments, you have a 60-day window to repay them," said Hoover. "Now these healthcare providers have to be extremely effective with their compliance programs in what they've done and what they've billed for. They've got to be prepared in case overpayments are found. They have a small time frame to decide what to do - whether to appeal or not - and make sure those payments are received back in time."
Harris agrees this is one of the biggest compliance issues currently dogging providers.
"With providers, their standard is to try to make that 60 days, and in a large system where you have a large amount of claims and overpayments to deal with, it's quite a challenge to make sure this timeframe is met," she said.