How to Conduct a GAP Analysis of Your Health Care Practice

How to Conduct a GAP Analysis of Your Practice. For Help, Call Liles Parker: 1 (800) 475-1906GAP Analyses are routinely used in practically every industry to assist an organization in identifying whether corrective actions are needed in order to bring an entity to an acceptable level of legal and professional compliance.  Our health care clients have consistently found that a GAP Analysis of their practices can be an invaluable compliance tool. A GAP Analysis can play an essential role in the successful development and implementation of an effective compliance program.  Moreover, it can greatly assist you in identifying both general and organization specific risks faced by your organization.  For example, with respect to physician practices, the Department of Health and Human Services (HHS), Office of Inspector General (OIG) has noted that the agency:

". . . recognizes that many physician practices may not have in place standards and procedures to prevent erroneous or fraudulent conduct in their practices.  In order to develop standards and procedures, the physician practice may consider what types of fraud and abuse related topics need to be addressed based on its specific needs.  One of the most important things in making that determination is a listing of risk areas where the practice may be vulnerable[1]

Additionally, OIG has expressly noted that its compliance guidance is intended to cover not only medical doctors but also a wide variety of other clinical professionals.  As the agency has indicated, “[f]or the purpose of this guidance, the term ‘‘physician’’ is defined as: (1) a doctor of medicine or osteopathy; (2) a doctor of dental surgery or of dental medicine; (3) a podiatrist; (4) an optometrist; or (5) a chiropractor, all of whom must be appropriately licensed by the State.”[2]  Furthermore, OIG has stated that “[m]uch of this guidance can also apply to other independent practitioners, such as psychologists, physical therapists, speech language pathologists, and occupational therapists."

To conduct a GAP Analysis, you will first need to conduct a baseline assessment of the legal, regulatory, contractual and professional requirements that must be met in order for you and your business to stay within the four corners of the law.   With this information identified, you will be well positioned to assess whether your organization's coding, billing, operational and business practices exceed, meet or fall short of your legal or contractual obligations.  While there are various ways to conduct a GAP Analysis, one method includes the following steps:

Step #1. Establish the Statutory, Regulatory, Ethical and Professional Baseline Standards to be Achieved and Maintained:

(a) Learn the rules that govern your profession and your business model.

(b) Identify and review proper coding and billing practices specific to your type of practice.

(c) Review ethical standards likely promulgated by the professional standards board in your State.

(d) Based on your review of the applicable standards, put together appropriate policies and procedures for your office.

(e) After identifying applicable regulatory and statutory requirements, assess the current practices of the facility.

(f) Review coding and billing activities, as well as the underlying documentation.

(g) Evaluate laws, regulations, case holdings, OIG fraud alerts and notices related to organizations like yours and / or services that you provider.

Step #2.  Conduct an Audit of Your Health Care Organization's Current Coding and Billing Activities, Operations and Business Practices:

(a) Pull a list of your claims billed over the last 30 / 60 / 90 days. Compile a chart which reflects all of the services you are billing and the various payors involved.

(b) Is your documentation compliant with the appropriate guidelines, such as LCDs, NCDs or private payor guidelines? If not, why not?  What impact, if any, do deficiencies have on whether a claim you have already submitted is payable?

(c) Evaluate leases, contracts and other business relationships to determine if they comply with Stark and Anti-Kickback laws. Are there any other laws governing your business practices?

Step #3. Apply the GAP Analysis to Help You Identify any Business or Clinical Practices Where Your Organization Fails to Meet the Baseline Requirements:

(a) Compare the baseline requirements for conducting your business with your actual practices. This is the essence of a GAP Analysis.

(b) After comparing these two sets of practices (ideal/legal vs. actual), determine if any deficiencies (such as overpayments or improper business practices) are present.

(c) Deficiencies should be noted so that an appropriate “risk issue” can be developed and included in your Compliance Plan, thereby highlighting the problem so that it will hopefully not reoccur.

Step #4. Use the GAP Analysis Process to Identify Where Corrective or Remedial Action is Needed:

(a) Have you identified an overpayment through the GAP Analysis process?  If so, any overpayments must be reported and returned within 60 days to avoid liability under the False Claims Act. [3]

(b) Take care to address any improper business practice. Consult qualified legal counsel to resolve potential conduct that may be a violation of the False Claims Act, Anti-Kickback Statute, Stark or other legal requirements.

You may ask, “Is this a good idea since it can result in the identification of overpayments or improper conduct”?  Good question. In our opinion - yes, it is absolutely necessary.  Otherwise, you are more than likely to continue down the wrong path, thereby increasing your potential liability. An overpayment or improper business practice will ultimately be revealed – it is in everyone’s interests, including yours, to fix a problem as soon as possible.

NATIONWIDE REPRESENTATION   Call: 1 (800) 475-1906.

Liles Parker attorneys and staff have extensive experience conducting these assessments.  Our attorneys are both seasoned health care lawyers AND have undergone special training and education so that they could become Certified Professional Coders (CPCs), Certified Medical Reimbursement Specialists (CMRSs) and / or Certified Medical Compliance Officers (CMCOs).  Questions?  For a free consultation, give us a call.  We can be reached at:  1 (800) 475-1906.


[1]65 Fed. Reg.  59434, 59438 (Oct. 5, 2000) (emphasis added).

[2] Id.; see 42 U.S.C. 1395x(r).

[3] For an overview of the issues you should consider when an overpayment has been identified, see our article titled "Overpayment Considerations When You Owe Monies to Medicare, Medicaid or a Private Payor." 

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