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Health Reform Mandates Compliance Programs
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On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (“PPACA”).  For the first time it mandates that as a condition of enrollment in Medicare, Medicaid, or CHIP, providers and suppliers establish and maintain a compliance program centered around yet-to-be-defined “core elements.”

Generally a compliance program is a system enacted within an organization that receives governmental resources intended to detect and deter internal fraud, waste, and abuse.

The Secretary of Health and Human Services (“HHS”), in consultation with the Office of the Inspector General (“OIG”) of HHS, is charged with establishing by rule the core elements that the compliance programs of providers or suppliers within particular industries or categories must meet. The Secretary will also determine the timeline for the establishment of these core elements.

Such "compliance programs" are not new.  In 1997, the OIG issued its first “compliance program guidance,” which was specifically intended for use as a model by clinical laboratories. Between 1998 and 2008, the OIG issued or supplemented compliance program guidance for hospitals, home health agencies, clinical laboratories, medical billing companies, DMEPOS suppliers, hospices, Medicare Part D organizations, nursing facilities, individual and small group physician practices, ambulance suppliers, and pharmaceutical manufacturers. The Centers for Medicare & Medicaid Services (“CMS”) issued its own compliance program guidance for Medicare fee-for-service contractors in 2005.

These "compliance programs" are not intended to be absolute checklists, but rather guidelines generally structured around seven elements that the United States Sentencing Commission has identified as those an organization must have incorporated into a compliance program to demonstrate that it exercised “due diligence” in detecting and deterring fraud, waste, and abuse of government resources.

These elements include: (1) developing written policies and procedures; (2) designating a compliance officer and compliance committee; (3) conducting training and education; (4) developing effective lines of communication including anonymous reporting; (5) auditing and monitoring systems; (6) enforcing disciplinary guidelines and excluding ineligible persons; and (7) responding to, correcting, and reporting detected problems.

The PPACA does not specify whether compliance plans will be required of currently enrolled providers and suppliers or only those seeking initial enrollment in Medicare, Medicaid, or CHIP. All providers and suppliers currently enrolled or planning to enroll in these programs should have in place a compliance program—one that meets the currently recommended criteria for their industry and that can evolve to meet new requirements imposed by the PPACA. Having such a program in place now will give providers and suppliers a head start when the new required core elements are adopted. It will also help ensure that providers and suppliers are policing themselves internally in the face of ever-more-intense governmental scrutiny.

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Health Reform Mandates that Health Care Providers Adopt Compliance Programs By Brandy Schnautz Mann


 
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U.S. government overpaid private insurance companies administering Medicare Advantage plans by as much as $3.1 billion in 2010, according to a new report from the Government Accountability Office (GAO).

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