When Doctors Resist Compliance Training

"No doctor, compliance training is not optional"

We often receive calls from clients asking for creative ways or guidance to get the doctors in their practice to do compliance training along with the rest of the office staff. The doctor doesn't have time or just wants to "review" the policies and procedures, which they won't. This seems to be a fairly common thread with compliance training and doctors.

Many offices have similar issues with doctors resisting training and as a medical office manager or compliance training administrator you may need to be less coddling or creative and more firm and direct. 

The bottom line is that HIPAA, OSHA and Medicare do not simply suggest training. It is REQUIRED that ALL EMPLOYEES receive compliance training annually (including management and particularly doctors). They don’t simply recommend this or say if it is convenient but that it is REQUIRED for compliance.

It may be necessary to send a message reminding ALL staff members of this fact and the importance of being in compliance for the safety of patients and staff, privacy issues, the legal requirements and financial/reputation ramifications for the practice as a whole due to violation or non-compliance.

Including the information on specific regulations may be useful to get the message across. For example:

The HIPAA Privacy CFR discussing administrative requirements for training can be located in 45 CFR § 164.530(b)(1) and for HIPAA Security 45 CFR § 164.308(a)(5).

Similar resources for OSHA can be found on the Guide to Compliance with OSHA Standards for Medical and Dental offices website. Note that each standard requires training.

Medicare and most insurance companies also require attestation (to affirm to be correct, true, or under oath) that ALL staff receives Fraud, Waste and Abuse training to maintain receipt of payment.

As for HR and Employment Law, we were recently contacted by a client about an unemployment claim issue. Because of the Doctor making a poor decision they will likely end up paying that unemployment claim when normally they would have been able to contest it. Due to that doctors lack of HR training, his bad decision will now cost the practice unnecessarily. Please see this previous article that spawned from this incident:
The greatest risk to any organization comes from within.


Another key item of importance is that workforce member can't just read over some notes on policies or procedures and be considered "trained". There needs to be a formalized consistent method of training that includes Documentation of the training processes, dates, etc. As the saying goes, if it isn't documented it didn't happen.

Compliance and Compliance Training is not optional and is very crucial to the legitimacy and success of your practice or medical facility. Make these requirements clear to your Entire Workforce as a fundamental part of your organization's culture and a non-negotiable condition of employment at your practice. End of story!

Source(s): http://www.hcsiinc.com, https://www.law.cornell.edu, https://www.osha.gov, https://www.teachprivacy.com

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Medicare Advantage Fraud: Temptation, Consequence, and Protection

Knowing the law and keeping careful records may head off fraud and significant legal expenses.

Medicare Advantage delivers Medicare Parts A and B coverage through a private insurer. To encourage companies to participate in Medicare Advantage, CMS uses risk scores to determine how much a sponsor will be paid for each member of a plan. Risk scores assign a value to determine how much a plan member may cost the plan. For example, an individual whose family has a history of cancer would have a higher risk score than an identical individual without a family history. The higher the risk score of a plan member, the more the company is paid for that member’s plan.

Federal government payments to Medicare Advantage plans are based solely on the number of members enrolled at each risk score—not on the services received by the beneficiaries. That payment arrangement creates two temptations: to inflate risk scores and to sign up as many members as possible.

Recently, several whistleblower suits have shown that people do succumb to these temptations. One of those lawsuits revealed the existence of a memo­randum allegedly sent to physician practices encouraging doctors to bring in elderly patients to sign up for Medicare Advantage by promising the patients complimentary parking and waiving their copayments. Justice Department officials ultimately determined that there was no wrongdoing and didn’t intervene. But this case and others like it show that Medicare Advantage is coming under heightened scrutiny, and health plans need to be ready for it.

Legal consequences 

Medicare Advantage fraud enforcement comes in two basic flavors: CMS enforcement actions and whistleblower lawsuits. CMS initiates an enforcement action when officials decide a plan sponsor is in substantial or repeated noncompliance with its contract with the agency. Enforcement actions range from civil monetary penalties to terminating the plan’s contract. Intermediate sanctions may include suspended plan payments or the removal of the company’s ability to enroll new beneficiaries into its Medicare Advantage programs. Because Medicare Advantage has been under heightened scrutiny from Congress and the media, CMS may step up the number and severity of its enforcement actions.

Whistleblowers may bring actions under the False Claims Act on behalf of the government if they find evidence of fraud. As more sealed cases are made public, more whistleblowers could come forward with greater confidence that they will not suffer retaliation. Whistleblower lawsuits can mean millions of dollars in litigation costs, even when the lawsuit proves to be frivolous or off-base.

Four protective steps

What can health plan executives do to head off any problems with fraud? First and most fundamentally, know the law and abide by it. It is impossible for a plan sponsor that does not know what is legal and illegal to administer its plan legally. The leaders at a health plan must ensure that all employees of the company understand what constitutes fraudulent activity and how to prevent any such activity. They should avail themselves of any available resources to help them understand the requirements by which they must abide. That could mean discussions with an attorney or using free publicly available resources, such as the guidances posted on the HHS website.

Second, confirm that all required information, including billing information, is correct and complete. If an issue arises, accurate records will be key to demonstrating the legality of the provider’s policies. Third, implement a compliance program to ensure that the plan sponsor is fulfilling the required competencies for Medicare Advantage providers. Finally, report any violations promptly. All Medicare Advantage plan sponsors are required to have a mechanism to report abuses. No one may retaliate against an employee for making a report. Finding and actively resolving any violations could save millions of dollars in litigation costs years in the future.

Help fight Medicare fraud

Medicare fraud wastes a lot of money each year and results in higher health care costs and taxes for everyone. Examples of Medicare fraud include:

• A healthcare provider billing Medicare for services you never got
• A supplier billing Medicare for equipment you never got
• Someone using your Medicare card to get medical care, supplies, or equipment
• A company using false information to mislead you into joining a Medicare plan

You’re the first line of defense against Medicare fraud. You can help by guarding your Medicare number --- treat it like a credit card.

More ways to protect yourself, your loved ones, and Medicare from fraud:

• Learn tips to prevent fraud
• Learn how to spot fraud
• Learn how to report fraud
• Find out what you need to know if you’re in, or thinking about joining, a Medicare health or drug plan

Sources: Merle DeLancey & Lyndsay Gorton @ http://www.managedcaremag.com/, https://www.cms.gov/

For more information on this and other healthcare topics related to HIPAA, OSHA, Medicare and HR compliance please email support@hcsiinc.com or visit our website at http://www.hcsiinc.com 
Join our LinkedIn group at: http://bit.ly/1FWmtq6

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The Fight Against Medicare Fraud and Abuse

Fighting Medicare Fraud and Abuse 

The health care reform legislation contains several provisions that affect fraud investigations and over-payments. One change that you will want to really keep an eye on is the change that permits HHS to suspend payments to you while an investigation is taking place if the investigation results from a “credible allegation of fraud.” The bill does not contain any definitions of what constitutes a “credible allegation of fraud” or how this new authority will be implemented. The HHS Secretary will have the authority to promulgate regulations covering all of these types of details.

Depending on how this authority is implemented, this could have really significant impacts on your practice. It means that reimbursement will be terminated during the entire course of the investigation. This will put tremendous pressure on a practice and in many cases will be enough to put them out of business. The bill currently does not give us any detail on implementation.

We will keep you aware of the regulatory developments in this area. This is a “punishment before proven guilty” type provision.

You can also expect to see litigation over the legality of this provision of the bill.

In order to avoid fraud and abuse in your practice, you may utilize our “RAC” materials posted on our web site at www.hcsiinc.com  You may sign on to the web site with your ID codes, select the “Updates/News” link on the left side of the page and scroll down to the “Medicare section to locate the RAC materials.

Stark Law Exceptions Reminder

Professional courtesy, when extended to a physician or entity who refers "designated health services" can implicate the Stark Law. The Stark Law is a strict liability statute and the penalties for violating the statute can include denial of payment, refund demands, civil monetary penalties, and exclusion from the Medicare program. The Stark ban on physician self-referral generally makes it unlawful for a physician to refer Medicare patients for radiology tests, clinical laboratory tests, physical or occupational therapy, home health care, or other such "designated health services" to an entity with which the physician has a "financial relationship".

A financial relationship can be an ownership or a compensation arrangement with an entity. A compensation arrangement is defined to include any arrangement involving any remuneration between a physician and an entity, including remuneration that is "in cash or kind". The provision of free or discounted services to a provider of "designated health services" or the provider's family would be such prohibited remuneration. There is, however, an exception to the Stark regulations to allow for certain extension of professional courtesy. In order to fall within the Stark exception, all of the following elements must be met:

·        The professional courtesy must be extended to all members of the entity's medical staff in the case of a hospital, or all members of the local community or service area, in the case of a physician practice

·        The healthcare items and services are a type routinely provided by the entity or practice

·        The professional courtesy policy must be set forth in writing and approved in advance by the entity's governing board(s)

·        The professional courtesy must not be extended to Medicare or other federal health program beneficiaries unless there is a showing of financial need, and

·        The arrangement cannot violate the anti-kickback statue or any state law