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May, 2016

Chiropractic Compliance Do's and Don'ts

By Ronald Short, DC, MCS-P

In October 2000, the Office of Inspector General for the Department of Health and Human Services published its guidelines for a voluntary small- to medium-office compliance program. The guidelines spanned 19 pages. In 2010, the Patient Protection and Affordable Care Act made the office compliance program mandatory as a condition of enrollment in Medicare, Medicaid or CHIP.  Even though the deadline has not yet been set for when the office compliance program needs to be in place in your office, you are expected to have one in place.

The presence of an effective compliance program in your office provides substantial protection from fines and penalties. It indicates to regulatory agencies that you are concerned with operating your practice in compliance within the laws, rules and regulations, and that you have taken appropriate action to do so.

The demand for office compliance programs is increasing and there are various products available on the market. Some are good and some are not. With all this in mind, here are some do's and don'ts to consider when developing your office compliance program:

DO Take the Issue of Compliance Seriously

Over the years, various "fads" have come and go. Some, like HIPAA, are still with us and are here to stay; others, not so much. Compliance is not a fad and is here to stay. All health care providers are required to follow a slew of regulations and it is extremely difficult for government regulators to police all providers. Having an office compliance program operating in your office indicates you are aware of the regulations and are systematically reviewing and refining your procedures to ensure you are following those regulations. When regulators see you have an active office compliance program in your practice, they know they can focus their attention elsewhere.

compliance - Copyright – Stock Photo / Register Mark DO Get a Compliance Program in Place

As alluded to, the presence of an office compliance program offers you substantial protection from fines and penalties for any wrongdoing. In one real-life case, the presence of an effective office compliance program made the difference between several hundred thousand dollars in fines and no payment at all. For an office compliance program to offer this kind of protection, it needs to be in place before investigations begin. It is better to be 10 years too early than 10 minutes too late.

DON'T Get a Manual, Put It on a Shelf and Consider Yourself Protected

A common misconception with compliance is that having the manual is enough. An office compliance program is not about a book that sits on your shelf. It is about the policies and procedures you have in place and use on a regular (sometimes daily) basis to ensure your patient encounters are documented properly; all claims are billed properly to the correct people (and/or third-party payers); everything relating to patients is private and secure; and dozens of other details. The policies and procedures codified in the manual need to be properly applied for you to be protected.

DON'T Copy a Colleague's Compliance Program

A properly developed office compliance program is not inexpensive, but for the protection offered, it is a bargain. Sometimes the temptation is to save money by borrowing and duplicating a friend's compliance manual. (I once had a doctor try to "sell seats" at his compliance audit to recover the cost.) Resist this temptation.

Compliance programs are customized to the office and the particular unique requirements of that office. The Office of Inspector General for HHS (who is responsible for the oversight of the compliance program requirements) will not even post a sample office compliance program on its website. According to the OIG, each office compliance program should be unique to the office for which it is developed.

There are many elements to a properly developed and executed office compliance program. Getting one element wrong jeopardizes the effectiveness of the entire office compliance program.

DON'T Try to Do It Yourself Unless You Have Some Training

It is not impossible for you to put an effective office compliance program in place yourself, but you will either need some training or very close guidance from a consultant who is trained and certified. Don't think you are simply going to read a few regulations and develop the ideal compliance program for your office in a day or two, or even a month or two.

DO Get Advice From a Trained, Certified Compliance Professional

The world of compliance is complex and not easy to navigate. A good office compliance program will include OSHA, HIPAA, CLIA (if applicable), OIG rules, Stark and anti-kickback laws, CMS regulations, and state laws. This is not an area for the faint of heart. I am not going to say it is impossible to develop your own compliance program, but the time and effort required for the average doctor to do it properly without help would be prohibitive.

This brings up the question: What kind of help do you need? The short answer is that you need the assistance of someone who is trained and certified in compliance. The trained and certified individual should have completed a prescribed course of training and attained at least a minimum passing score on a national board examination. This proves they have received a minimum level of training and retained enough of that information to pass the exam. Not only that, once the individual is trained and certified, they need to complete a minimum level of continuing education annually to retain their certification.

So, how do you find someone who is trained and certified in compliance? Look at their credentials. There are four nationally recognized organizations that provide training and certification in health care compliance:

The ideal consultant is a doctor of chiropractic with practice experience and with one of these certifications.

DO Keep Your Compliance Program Active and Current

As I stated before, the office compliance program is not just a book sitting on a shelf. It must become an active part of your practice. You must monitor the various agencies for changes in regulations, and modify your policies and procedures as necessary. You also must monitor your policies and procedures to ensure you are getting the desired results. If a policy and/or procedure is not providing the desired result, then modify it accordingly, and document when and why the modification was made.

DON'T Develop Policies and Not Implement Them

Creating your compliance manual is just the first step to an effective office compliance program. You need to review each individual policy to ensure it exactly fits your practice. Modify if necessary, and then date and sign it. You then need to implement that policy in your office before moving on to the next one.

The worst thing you can do is develop a manual full of policies and procedures you do not follow in your office. You could actually get into more trouble by having the policies and not following them than you could for not having them in the first place.

DO Write Detailed and Precise Policies and Procedures

Each policy should outline the intended outcome. For example, if I were to write a policy for an office regarding the use of the Advanced Beneficiary Notice of Non-Coverage (ABN) for a Medicare patient, it might look something like this:

"This office shall inform Medicare patients of their potential financial liability to avoid confusion and misunderstandings. The ABN shall be used voluntarily at the initial assessment visit to inform patients of their financial liability for services that are statutorily not covered by Medicare. When the patient reaches Maximum Medical Improvement (MMI) during their course of care, they shall be presented with an ABN informing them of their potential financial liability for future formerly covered services."

This would be followed by detailed procedures describing how the ABN would be filled out, and how and when it would be presented to the patient. This level of detail is important to allow each member of the staff to be consistent when performing that particular task (in this case, giving the Medicare patient an ABN).

Compliance Is Not Going Away

Compliance has become a necessary part of our practices. The regulations have become so extensive that the regulators are having a difficult time enforcing everything. When they visit an office with a properly developed and executed office compliance program, they know they can focus their attention on other practices.

Executed properly, the office compliance program can prove to be a great benefit to your office. One study even indicates that a properly functioning office compliance program can result in increased income by monitoring and quickly correcting deficiencies that would have resulted in denied claims. However, when an office compliance program is not properly executed, it will be ineffective and can become a liability.


Dr. Ronald Short is a certified medical compliance specialist and a certified professional coder. He has authored numerous books on Medicare including The Medicare Documentation System. He also teaches seminars on Medicare, coding, billing, documentation and compliance. You can contact him at . More information about this and other Medicare topics is available at www.chiromedicare.net.

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