medicare compliance

Over 65 million people in the U.S. depend on Medicare to get the healthcare they need. Remaining in good standing with Medicare has several advantages. As a compliance officer or critical decision-maker, you can help your healthcare organization avoid exclusion from this valuable program by creating a comprehensive compliance program and using software to streamline your compliance processes.

Compliance Program

A comprehensive way to avoid Medicare exclusion is to develop an organization-wide compliance program, one of the Centers for Medicare and Medicaid Services (CMS) requirements. With oversight from the compliance officer, a comprehensive compliance program should contain the following components, which reflect other Medicare requirements.

Policies and Disciplinary Procedures

One of the most essential functions of a compliance program is to enforce your company’s Medicare standards and implement consequences for non-compliance. These policies should list safety and ethics requirements consistent across all departments. Also, each infraction’s sanctions and disciplinary actions should be communicated clearly and carried out fairly with sufficient documentation.

Medicare Compliance Training

Another CMS requirement for healthcare entities is to offer fraud, waste, and abuse (FWA) training to all providers and staff. One of the most important aspects of FWA training is differentiating the following terms:

  • Fraud is intentionally committing deception or misrepresentation in billing, prescribing drugs, or ordering tests or procedures. An example is knowingly billing for services a doctor hasn’t provided.
  • Waste refers to the overuse of medical services, resulting in unnecessary expenses. For example, a doctor might order an expensive diagnostic test when a less costly but equally effective test exists. Waste is not always intentional.
  • Abuse includes actions that don’t follow or reflect sound medical and financial best practices. Examples include using an inappropriate code on a claim or billing for a service Medicare doesn’t cover.

Regular Risk Assessments

Each healthcare organization, hospital, or private practice has unique vulnerabilities that make it more prone to non-compliance incidents. A risk assessment helps compliance officers and other leaders identify risks for non-compliance and anticipate when they’re most likely to emerge. For example, a risk assessment can shed light on conditions that make fraud, waste, and abuse most likely to occur. The outcome of a risk assessment should be a list of recommendations for corrective actions and systemic improvements.

Medicare Compliance Audit

While a risk assessment highlights factors that make non-compliance more likely, a Medicare compliance audit measures the level of regulatory adherence during a specified period. For example, an audit should cover issues like the accuracy of claims, appropriateness of payments, and timeliness and necessity of billed services. Regarding regular audits, healthcare organizations must complete a Fraud, Waste, and Abuse (FWA) Assessment based on CMS requirements.

Medicare Corrective Action Plans

In addition to identifying and reporting non-compliance incidents, Medicare compliance enforcement must also include action or work plans designed to correct violations and ethical and legal standards. Moreover, compliance officers must ensure timely implementation of these corrective actions, typically based on the organization’s compliance policies and U.S. Office of Inspector General (OIG) guidelines.

Mechanisms for Clear and Protected Communication

A comprehensive compliance program enables effective communication that goes both ways. On the one hand, the organization must communicate clearly the policies, procedures, and repercussions related to Medicare regulations and incidents of non-compliance. On the other hand, employees should be able to ask questions and get clear answers about Medicare compliance. More importantly, workers should enjoy protection from retaliation and discrimination when they report unsafe working conditions, unethical behaviors, or incidents of non-compliance.

Using Software to Maintain Medicare Ethics and Compliance

Managing a compliance program and helping providers and staff maintain Medicare compliance is anything but simple. Fortunately, a compliance officer can leverage the power of software to streamline all the work. Compliance software makes it easier to facilitate training, conduct internal audits, implement Medicare corrective action plans, and detect and report FWA incidents. More specifically, a comprehensive software package helps simplify the following tasks:

  • Monitor regulatory changes in Medicare and other federal programs
  • Create and disseminate the organization’s compliance policies
  • Schedule training for all personnel across multiple locations
  • Track employees’ training progress and completion scores
  • Manage risk assessment and auditing processes
  • Record non-compliance incidents
  • Create reports of incidents
  • Provide reports on the organization’s status of Medicare ethics and compliance
  • Summarize and report corrective actions
  • Store documents for easy access and distribution
  • Monitor intake of worker suggestions and reports of non-compliance
  • Integrate with electronic medical records and other systems

See How It Works