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Model Compliance Program for Individual Physicians and Small Group PracticesThe Office of Inspector General - Health and Human Services, published a "Draft OIG Compliance Program for Individual and Small Group Physician Practices." A copy of the program is available from the Billing Compliance office or is available on the OIG website at: http://www.dhhs.gov/oig/oigreg The model program is based on seven basic compliance elements: 1. The development of written standards, including a code of conduct or mission statement. 2. Comprehensive education and training of staff 3. Assignment of compliance oversight to a designated person 4. Monitoring of services 5. Establishment of effective lines of communication 6. Investigation of all potential compliance issues and concerns 7. Establishment of disciplinary standards and corrective actions The Draft Compliance Program contains information that should be of value to every physician. Particularly worthy of review are the "risk areas", (i.e., areas that may be targets for OIG investigations). Among risk factors identified in physician practices are: Reasonable and Necessary Services Local Medical Review Policy (LMRP). When HCFA does not have a national policy on the coverage of a service, carriers are able to develop their own policies, known as local medical review policies. Physician practices are to bill federal health programs only for items and services that are covered. To determine if an item or service is covered by Medicare, physician practices must be knowledgeable of the LMRP's applicable to the jurisdiction in which they practice. According to the OIG, "when the LMRP indicates that an item or service may not be covered by Medicare, the physician practice is responsible to convey this information to the patient so that the patient can make an informed decision concerning the health care services he/she may want to receive. Physician practices convey this information through Advanced Beneficiary Notices (ABNs)." Physician Relationships With Hospitals Teaching Physicians. The OIG advises that physicians ensure the following with respect to services provided in the teaching physician setting: 1. Only services actually provided are billed; 2. Every physician who provides or supervises the provision of services to a patient is responsible for the correct documentation of the services that were rendered. 3. Every physician is responsible for assuring that in cases where the physician provides evaluation and management services, a patient's medical record includes appropriate documentation of the key components of the services provided or supervised by the physician, as well as documentation to adequately reflect the procedure or portion of the services provided by the physician; and 3. Every physician must document his or her presence during the key portion of any service or procedure for which payment is sought. Physician Billing Practices Professional Courtesy. For the first time, the OIG discusses an issue that has been of great concern to the physician community, the use of professional courtesy. The observations by the OIG that are summarized below seem to recognize that professional courtesy - especially if it is extended to people who are not beneficiaries of a federal health care program (e.g., Medicare, Medicaid, and CHAMPUS/TRICARE) - may not violate any federal laws. 1. Waiving the entire fee for services rendered to a group (including employees, physicians and/or their family members). This may not violate the law as long as membership in the group receiving the courtesy does not take into account either directly or indirectly any member's ability to refer to, or otherwise generate federal health care program business for the physician. 2. Waiving copayments for services rendered to physicians, referring and non-referring alike, their employees and family members. This would not implicate the anti-kickback statute as long as the courtesy is not extended in a manner that takes into account directly or indirectly, the ability of a person to refer to, or otherwise generate federal health care program business for the physician. 3. Waiving of copayment for a Medicare beneficiary (or beneficiary of another federal health care program) who is not financially needy. This may violate the law that prohibits inducements to beneficiaries (section 1128A(a)(5) of the Social Security Act).
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