Liles Parker PLLC
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We Defend Healthcare Providers Nationwide in Audits & Investigations

How to Implement a Compliance Plan in Your Practice

Confused-Doctor(September 17, 2015): Despite the fact that Medicare and Medicaid requires that participating providers implement a compliance plan, most small providers have yet to complete the necessary steps to accomplish this requirement.  “My office manager went to a continuing education program, and she’s come back telling me we need a compliance program. I don’t know about that. I know I need to be in compliance with all those rules and regulations, but it seems to be complex and confusing. Do I really need one? How do I put a program into place without spending enormous sums? We’re a small practice and we don’t have a lot of extra time and money to spend on compliance activities.”

This is how my clients often approach me with questions about compliance programs. Or, they have been the recipient of an audit letter from either Medicare or a private insurer. Let’s face it, the requirements for compliance programs are here to stay. Not only are compliance programs now required by the federal government for any provider who receives Medicare or Medicaid reimbursement (see section 6401 of the Affordable Care Act), they are also required by many private insurance companies. Within the last year, I have seen increasing numbers of network provider contracts from private insurance companies include a requirement that the provider have a compliance program. So, having a functional compliance program is no longer an option but a requirement.

To that end, over the next year, we will be exploring the basic elements of an effective compliance program, as well as topics related to a solid compliance program. Let’s start with what a compliance program is and is not. A compliance program is not a document that is placed in a binder on a high shelf in your office, to be dusted off only annually or when faced with scrutiny by insurance companies or, God forbid, state or federal regulators. Instead, a compliance program should become part of the fabric of doing business in your practice. When implemented correctly, a compliance program can help identify potential trouble spots in your practice and give you a framework for addressing those trouble spots. Of course, a functioning and effective compliance program can also help minimize fines and, if things go south, could keep a civil matter from turning into a criminal matter.

A compliance program is also not a mumu – one size does NOT fit all. Just as there are differences between patients, there are differences between practices, the risks they face and the best methods of addressing those risks. An effective compliance program recognizes that while the structure of most compliance programs is similar, it takes into account the practice’s size and sophistication, the medical specialty, and the patient population. For this reason, compliance programs in a box or purchased off the Internet really are not desirable and often cost a practice more money in customization and sometimes tears down the road. A perfect example is the recent settlement by Anchorage Community Mental Health Services in relation to a HIPAA breach, where the government noted the ineffectiveness of the “sample” compliance policies and documents the provider put forward as its compliance program.

The basic elements of an effective compliance program are not complicated. They are:

  1. Designating an individual to serve as compliance officer and creating a compliance committee, particularly for larger organizations.
  2. Implementing a standard of conduct and policies and procedures relevant to the practice’s operations.
  3. Conducting effective training and education.
  4. Instituting effective methods of communication
  5. Conducting internal monitoring and auditing
  6. Enforcing the policies and standards through well-publicized disciplinary guidelines
  7. Responding promptly to violations and taking appropriate corrective action.

Each month we will explore each of these topics, discussing how to implement a compliance plan, and how to do so in a cost-effective fashion. Along the way, we will also discuss various forms of guidance available to practices when you implement a compliance plan that is tailored for the specific needs and risks of your individual practice. Let’s start with one right away – the federal government itself. The Office of Inspector General of the U.S. Department of Health and Human Services (“OIG”) has published a number of “Compliance Program Guidances”, intended to help different provider types understand and implement compliance practices specific to and appropriate for their particular branch. One of the guidances is specifically written for individual and small group physician practices and published in October 2000. It’s available here: In fact, this document is so basic to a physician practice’s compliance program that I strongly recommend that every compliance program have this document printed off, included among the compliance program documents, and readily available for staff member review. Although this document was published in 2000 (and therefore refers to CMS as HCFA and doesn’t make reference to the Affordable Care Act), it can be considered a bit like the U.S. Constitution – a document that creates the foundation for what comes after and points to a better future.

H-Kocher-photo-2-199x300Heidi Kocher, Esq. is a health law attorney with the firm, Liles Parker, Attorneys & Counselors at Law.  Liles Parker has offices in Washington DC, Houston TX, McAllen TX and Baton Rouge LA.  Do you need to implement a complaince plan?  Call one of our experienced health care attorneys for assistance. For a free consultation, please call: 1 (800) 475-1906.

CMS Awards Zone 6 ZPIC Contract to SafeGuard Services

Audit(August 15, 2015): The Centers for Medicare and Medicaid Services (CMS) has awarded the contract for Zone Program Integrity Contractor (ZPIC) services for Zone 6 to SafeGuard Services, LLC. Zone 6 encompasses Maryland, Delaware, Washington, D.C., Pennsylvania, New Jersey, New York, Connecticut, Massachusetts, Rhode Island, Vermont, New Hampshire, and Maine. SafeGuard is the current program safeguard contractor (PSC) in this jurisdiction, and its functions as a ZPIC will be similar to its duties as a PSC. SafeGuard is also the ZPIC for Zone 1 (California, Nevada, and Hawaii) and Zone 7 (Florida).

As the new Zone 6 ZPIC, SafeGuard will be responsible for investigating suspected waste, fraud, and abuse among Medicare providers. ZPICs have the authority to conduct unannounced, onsite inspections of providers’ facilities, perform pre-payment and post-payment reviews of claims, impose payment suspensions, recommend to CMS that a provider’s billing privileges be revoked, and refer providers to law enforcement for investigation. In our experience, SafeGuard is among the most aggressive ZPICs in the country.

If you receive correspondence from SafeGuard Services or any other ZPIC, we strongly recommend that you contact an experienced health care attorney as soon as possible. You should never assume that ZPIC audits or inspections are merely “routine.”

Liles Parker attorneys assist all types of providers across the country with responses to Zone 6 ZPIC investigations, audits, and other administrative actions. If you have questions or concerns about a ZPIC investigation, please contact our office for a free consultation.

Liles Parker has offices in Washington DC, Houston TX, McAllen TX and Baton Rouge LA.  Our attorneys represent health care professionals around the country in connection with ZPIC audits of Medicare claims, licensure matters and transactional projects.  Need assistance?  For a free consultation, please call: 1 (800) 475-1906.


Medicare Advantage Payments Set to Rise in 2016

medicare-blocks-compressed(April 15, 2015): Despite a February proposal in which the Centers for Medicare and Medicaid Services (CMS) said 2016 Medicare Advantage payments would decline, on average, by 0.95%, Federal regulators are now saying 2016 Medicare Advantage payments will go up compared to 2015.

I. Medicare Advantage Payment Rates:

CMS estimates that payments to insurers that offer private Medicare plans will rise about 1.25% next year, and insurers will probably see their overall revenue increase about 3.25% as they deliver, and bill for, more intensive services.

According to March 2015 data, Medicare Advantage enrollment is at an all-time high. More than 17.3 million people are enrolled in the program, which has been growing at more than 8% annually for the past several years. Insurers argued that cuts to payments would hurt seniors in the form of lost choices, benefit reductions, and higher costs. Bipartisan groups in both chambers of Congress also sent letters to the CMS urging positive rates for insurers and a “stable policy environment.”

II. Medicare Advantage Risk Adjustment Models for CY 2015:

Because of the support, health insurers largely expected CMS to roll out favorable 2016 Medicare Advantage payment rates, but they were less sure about how the government would update the risk-scoring system.  In February, CMS said it would make a full transition to a new, updated hierarchical condition category methodology for 2016, which was first proposed in 2013. Insurers expressed concerns about this model because it would it would affect their risk scores and bottom lines.  Many, however, still believed CMS would gently transition to the 2014 risk-coding recalibration model, which uses the hierarchical condition categories. Medicare Advantage payments are adjusted for each beneficiary’s health status using those categories. The model allows plans to be paid more for patients who are sicker and have more complications.

In its final announcement, CMS wrote that it will blend the risk scores calculated using the 2013 CMS-Hierarchical Condition Category (HCC) and 2014 CMS-HCC models by 67% and 33%, respectively. CMS wrote that it strongly took into consideration the comments it received opposing the original proposal to use a “blend of the 2013 CMS-HCC model and 2014 CMS-HCC model in 2015.” CMS recognized that additional time is needed to transition to the 2014 model, and therefore agreed not to use risk scores from just the 2014 model.

Taking into consideration the final payment updates and changes for 2015, CMS was concerned that the use of the proposed 2014 blend percentages of 75% and 25% “would not have the same effects on payment stability that they had last year.” With this in mind, CMS decided to “blend the risk scores calculated using the 2014 CMS-HCC model with risk scores using the 2013 CMS-HCC model, weighting the normalized risk scores from the 2013 model by 67% and the normalized risk scores from the 2014 model by 33%.” CMS hopes this formula will help move to the updated model while also providing time for plans to transition to its use in payment.

The risk scores from the 2013 and 2014 CMS-HCC models will include the risk scores calculated from the institutional, community, new enrollee, and C-SNP new enrollee segments of the model. They will be used in Part C payment for disabled/aged beneficiaries enrolled in Medicare Advantage plans.

III.  Final Remarks:

With the increase in payments, there will undoubtedly be an increase in scrutiny for Medicare Advantage claims.  Do you know the requirement differences for Medicare Advantage claims?  Do you understand how the risk-coding recalibration in 2015 will affect how CMS views your billing practices?  Call us toll-free at 1-800-475-1906 for a free consultation on how your business utilizes Medicare Advantage.

Robert Liles represents health care providers in RAC and ZPIC appeals.Robert W. Liles, Esq., is a Managing Partner at Liles Parker, Attorneys & Counselors at Law.  He focuses his practice on internal audits/investigations, fraud defense, and compliance and regulatory matters. The attorneys at Liles Parker represent a wide variety of health care providers and suppliers in administrative and civil proceedings. For a free consultation, call Robert at 1 (800) 475-1906.