The Ever-Increasing Need for Chiropractic Regulatory Compliance Programs

 Frank E. Biedak, Esq.  November, 2005

The Office of Inspector General published expectations that practitioners will implement internal programs designed to insure compliance with the myriad of laws and regulations that govern health care providers.  Providers are beginning to take heed.  “The phone calls I receive regarding the need for compliance education and program implementation has increased dramatically. The Chiropractic profession in particular seems to be demanding such services.” 

I believe our approach to compliance is unique because I spend considerable time at the specific practice learning the “ins and outs” of how that particular Office operates.  While it would be easy and arguably more profitable to simply forward a “boiler-plated” program, a Compliance Program, if it is to be successful, and actually used, must be tailored to the particular practice.

 It is well-known that the OIG does not expect that a solo-practice’s compliance efforts will be as extensive as a Major Teaching Hospital’s programs.  In fact, the OIG has publicly stated that phasing in a program is perfectly acceptable.  Our Program takes that approach because it permits the practice to concentrate its initial efforts in potential problem areas identified through the onsite visit and other known “high risk” functions.

One of our most popular Compliance services has proven to be chart coding and auditing.  The “triad” of medical record documentation, coding, and billing has proven to be one of the most problematic for Massachusetts chiropractic physicians.  Our Compliance program includes a random sampling of medical records and bills to provide the Practice with an external opinion regarding the coding and regulatory compliance of the documentation and billing.  Our audit provides strong opinions and feedback to our clients.  Additionally, we “leave” the practice with a recommended initial Audit Worksheet that will permit its own “internal experts” to perform ongoing compliance studies that also focuses on the medical necessity component of treatment. 

What is the FUSS ABOUT COMPLIANCE?

The Government has estimated that as high as  much as $65,000,000,000.00/year  could be paid out improperly by Medicare/Medicaid and other government funded efforts. It is quite likely that only a small percentage of that amount is due to one’s intentional acts to defraud the government.  The problem of educating providers about the importance of proper coding, billing and documentation has never been higher. 

Thousands of providers and individuals have been banned from the Medicare/Medicaid programs.   Quit Tam, or “whistle blower” suits  have increased dramatically with 109 more cases filed in 1998 compared to just two years earlier. Advertising, mergers, joint ventures and purchases and sale of supplies and equipment are now on the government’s “radar screens.”  A provider is under more scrutiny today than ever, and in most cases, a provider is completely unaware that he/she/it is being watched. 

The Health Insurance Portability and Accountability Act (HIPAA) significantly funded the fraud enforcement area and created an interagency approach  that did not necessarily exist previously.  A provider today needs to be aware of the Civil False Claims Act (31 USC s. 3729), its Criminal counterpart at 42 USC s. 1320a-7b(a));  Stark (42 USC s. 1395nn), The AntiKickback Statute (42 USC s. 1320a-7b(b)),  various other Federal laws such as RICO, Mail and Wire Fraud and numerous State Laws, Regulations and Professional Licensing Requirements .  

As costs escalate, and reimbursement remains the same, or in some cases even decreases, a provider, especially solos and small practices will be hard pressed to obtain the wealth of knowledge necessary to adhere to the network of rules/laws governing the practice of medicine/chiropractic.

If you did not know before, now you understand a little bit of what all the “fuss is about!”

 OIG ESTABLISHES ESSENTIAL ELEMENTS TO A PROVIDER’S COMPLAINCE PROGRAM

The Office of Inspector General published its eleven page Small Group Physician Practice Compliance Program in the Federal Register on October 5, 2000.

The OIG’s compliance program would include small and solo-practices and directly involves Medical Doctors, Chiropractors. It is highly likely that other practitioners like PT’s and OT’s would be well served to take heed.

In providing the guidance, the OIG said that it understood that smaller practices would face financial constraints in implementing such a program.  However, it is also equally noticeable that the providers (large and small) are expected to have such a program. 

It is important to implement a program that works for the individual practice.  The OIG warns that it is better not to have a program than to implement one and let it “collect dust.”  Attorney Biedak implements such programs after briefly meeting with the provider and gaining an understanding of the practices concerns and constraints. 

“The hallmark of my compliance program counseling is gearing it to the individual practice. The programs are generally phased in, and start with small internal audits of the provider’s records and bills. Walking providers through the process, while ensuring them that the cost of implementing one is not prohibitive are clearly what sets us apart from others involved in this area.”

The Program includes the Seven Essential Area, which are:

1. Written Standards of Conduct (code of Conduct) and Operational Policies and procedures;

2. Designation of a Compliance Officer (a very easy task in smaller practices);

3. Education

4. Implementing a Complaint process and procedure;

5. Implementing a system to identify and respond to potential improper/illegal activities (including   employee discipline)

6. Ongoing audits and monitoring; and

7. Setting up documentation that show follow through and corrections.

“Compliance can be scary because the overwhelming and often changing laws. Additionally, with so many high cost “in-town” law offices and “consultants” available, providers are rightfully concerned about the cost of such a program. I have discovered that we can eliminate fear by education.  I also know first hand that our rates are far more favorable than others, thereby permitting our clients the opportunity to actually implement an effective, ongoing program at great savings.  Most importantly, my clients get personal attention, because as a solo-practitioner, I completely understand that concerns and constraints.  We implement a program that meets the OIG’s standards and that actually work for the individual client.”

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Frank E. Biedak ESQ.

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