Being “compliant” with procedural coding conventions and payer policies and requirements means that the professional group makes every effort to bill correctly. A compliance plan is the practice’s organized effort to assure correct coding, identify and correct errors, and address ambiguities in a consistent manner.

Why is billing compliance important? If auditors determine that a physician has systematically but innocently billed incorrectly, any overcharges must be paid back, interest may be applied, and the physician may be fined $10,000 for each incorrect claim, with the possibility of treble damages. If the physician “knowingly and willingly” submits fraudulent claims, the crime is a felony, with the potential for a $25,000 fine, 5 years in prison, or both. Decertification from Medicare is likely, making it exceptionally difficult for an anesthesiologist to be gainfully employed at any facility that accepts Medicare patients. Ignorance is no excuse when it comes to billing the federal government, as was well-outlined in the July 1997 issue of the http://www.asahq.org/Newsletters/1997/07_97/Pres_Pg0797.html.

Although a compliance plan does not protect a group or physician from having to repay overcharges or eliminate the chance for fines, a group that demonstrates commitment to being compliant through implementing and following a plan will be much more likely to reach a reasonable settlement with the government. I know of a number of groups, including my own, that identified problems through claims review, proactively addressed the problems with the government, and reached a fair settlement.

The Office of the Inspector General (OIG) has published a model compliance plan that includes these seven elements:

For those who like to go to the primary source, this link will take you to a reprint of the Federal Register issue where the OIG published the model plan:http://oig.hhs.gov/authorities/docs/physician.pdf.

The ASA Newsletter also includes a monthly column on practice management. Over the past 10 years, many columns have addressed compliance issues and creation of a compliance plan. For those with an interest, I suggest reviewing the many articles archived at the ASA site. Some of these articles appeared in the ASA Newsletter in October 1997, December 1999, November 2000, and August 2002, available at http://www.asahq.org.

For purposes of evaluating a practice, asking the following questions may prove helpful in determining the group’s commitment to compliance.

The answers to all these questions should be a resounding “yes!” Although one can think of dozens of questions to ask about compliance, hearing any “no” answers to these very basic questions should be exceptionally worrisome. If you are an employee of a group that performs billing on your behalf, you are ultimately responsible that the billing is correct. Given your risk of monetary loss or even jail time, it is absolutely essential that you make sure your prospective employer takes compliance seriously.