Fraud and Abuse

Prevention through compliance programs

“Adopting a voluntary compliance program is a lot like practicing preventative medicine; it helps identify and treat small problems before they become big problems.”
Inspector General June Gibbs, OIG News Release, “Inspector General Issues Draft Compliance Program Guidance for Physician Practices,” June 7, 2000.

What is all the hype about? The Office of the Inspector General has made it a priority to safeguard the government health programs from fraud and abuse. The penalties for violations are stiff, including possible fines, imprisonment, and exclusion from federal healthcare programs. Fortunately, the government has made it very clear what it considers to be “risk areas,” so practices know where to focus their resources.

What is a compliance program? Compliance programs are a mechanism by which a practice may better protect itself from fraudulent or erroneous conduct. The OIG has listed seven basic elements that should be included in a good compliance program.

Are compliance programs mandatory? No. The OIG has clearly stated that compliance programs are not mandatory. However, by publishing these guidelines, it is evident that the OIG finds compliance programs very important and is strongly encouraging their implementation. In addition, there are mandatory sentence reductions for effective compliance programs under the Federal Sentencing Guidelines.

Are they beneficial? Yes. There are innumerable benefits in going through the process to implement a compliance program. The OIG has listed what it believes are the main compliance program benefits.

What isn’t a compliance program?
Quite simply, a compliance program isn’t a book titled “Compliance Program” that sits in the office manager’s shelf. Not only has the OIG stated that this does not suffice, it may even create additional liability.

What is involved in implementing a compliance program? The first step is to take a baseline measure of where the practice stands with regard to compliance efforts. This may include an audit of legal documents, contracts, medical charts, and bills. Based on these findings, an attorney will assist the practice in correcting any problems and implementing any necessary policies or a code of conduct. Then, the entire staff should be educated on the practice’s commitment to compliance, any new policies, and any new procedures.

OIG’s list of Benefits of a Compliance Plan

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OIG’s seven basic compliance program elements

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OIG’s suggested practice policies

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Risk areas

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