Plans and Programs for Corporate Culture Compliance

Sophomore (College 2nd year) ・Healthcare&Medicine ・APA ・3 Sources

A core aspect of corporate enforcement is the use of conformity and uniform practices to minimize illegal behavior. The other element is tasked high-level employees, such as the enforcement captain, with ensuring compliance by following the defined standards and procedures. (Fabrikant and colleagues, 2016). The third factor is to exercise due diligence by not appointing senior executives to positions involving criminal activity or enforcement violations. Consequently, precautions such as performing background checks on employees are required (Mikula, Abraham & Townshend, 2016). The standards and protocols should also be shared with those who are affected. This can be accomplished by informing and teaching individuals about the enforcement program. Noncompliance monitoring, auditing, and reporting system are also important. These systems should allow workers and customers to report any criminal activities without the fear of being victimized. The next component involves enforcing the standards through providing incentives for those who comply and disciplinary actions for offenders. Such disciplinary and reward programs may be implemented through the human resource department and consequences of non-compliance, such as termination of work contract should be known to all participants. The seventh component is implementing a corrective action by immediately addressing misconducts and ensuring similar breaches are avoided in the future. Hence, the compliance program may be modified as suitable, for example, though establishing a more reliable enforcement, and continual efforts to update compliance plan policy (Fabrikant et al., 2016).

Roles and Responsibilities of Staff Involved in Implementation of a Compliance Plan

The HIM Compliance Specialist is responsible for overseeing and monitoring the implementation of HIM compliance programs. He is responsible for the education and training of all stake holders in the program including provision of all relevant documents. In training programs, he is responsible for ensuring that all relevant documents such as agenda, handouts, minutes etc. are available. He ensures that any contracted parties and coding consultants understand and adhere HIM compliance programs. He ensures the accuracy of the coding programs by conducting regular audits and monitoring all ongoing coding. He then conveys the audit feedback to affected staff and physicians. He should also analyses the coding for patterns and any variations. He then compares these trends and variations with national values so as to identify any variations needing investigation. On coding and medical issues claims, he reviews the denials and rejection and where necessary implements corrective plans such as educational programs. Conducting investigations on changes in coding practices and initiating corrective measure to this is also his responsibility. He receives and investigates noncompliance claim reports and communicates the same to the Corporate Compliance Officers with recommendations of any displinary measures to be taken against the violators. He ensures passage of information concerning any regulation, policy or guideline changes to the involved personnel. Being the most informed officers, he acts as a resource to all other officers and staff on matters involving coding and documentation standards, guidelines and regulatory requirements. Overall, the compliance specialist monitors and recommends revision of the HIM programs and is as a member of its committee. (Mikula, Abraham & Townshend, 2016).

Assisting the role of the HIM Compliance Specialist is the Corporate Compliance Committee responsible for monitoring and evaluating the compliance plan. This committee consists of about eight Compliance Operation Leads/Officers that represent the organization’s operational departments including finance, risk management, billing, legal, human resources, quality assessment, and clinical operations. The committee’s role is to continually analyze the firm’s risk environment, specific risk areas and legal requirements. Furthermore, the committee assesses and revises existing compliance policies and procedures to maintain compliance. (Mikula, Abraham, & Townshend, 2016).

The coding compliance officer is responsible for all the matters pertaining coding, billing and reimbursement compliance. Specifically, he reviews all reports published by HCFA, OIG or any third parties on fraud, advisory opinions or other publications relative to billing, coding and reimbursement compliance. He also assesses and analyses the compliance system to eliminate any compliance problems and noncompliance activities. Where there is a complex case of noncompliance activities, he uses a systematic approach to identify and resolve them. He also works with the charge master and cost report personnel to ensure that proper compliance subject to rules and regulations is maintained.

Next, a Business Unit Compliance Lead/Officer is responsible for compliance training and ensuring participation of all employees in the compliance training. Other roles include assisting the CCO with requested compliance audits, investigation and resolution of reported incidents, and acts as a communication liaison between the CCO, the committee and the organization (Fabrikant et al., 2016).

There is an Inpatient Audit Consultant responsible for conducting coding assessment at client’s site to help them stay in track with compliance goals. He should conduct in-depth audit and presents the results to the clients.

The outpatient and charge master audit consultant assess clients’ code. This helps the hospital clients keep track of their outpatients’ compliance goals. He audits the codding and reports the results to the client. He also helps the client update their charge description masters.

Roles and Objectives of Two Healthcare Enforcement Agencies that Influence Noncompliance Reporting

First, the Title II of the Health Insurance Accountability and Portability Act (HIPAA) of 1996 set the national standards in healthcare records. It also provides the universal identifiers for service providers, employees and health plans while addressing matters of security and privacy in health information. The company sets compliance guidelines and it is responsible for prosecuting those that fail to comply with the set standards. The agency audits, investigates, inspects, and evaluates linking to the delivery of healthcare in the US (Mikula, Abraham & Townshend, 2016).

Second, the Office of Inspector General (OIG) of the Department of Health and Humans Services provides resources for ensuring the knowledge of compliance, and how corporate governing bodies can implement the compliance procedures. Its objective is to protect the integrity of health and human welfare programs for the beneficiaries. The agency motivates and encourages a culture of compliance. It has also established a Code of Conduct by which third parties need to follow to act in the best interests of the consumer (Buchbinder & Shanks, 2016).

Procedure for Reporting Coding Noncompliance

Coding noncompliance arise when any of the following malpractices are committed. Up coding, this occurs when a code whose description reports a more intense condition or a more complex procedure than what really occurred is used. Clustering, this occurs when the personnel, instead of assigning an accurate code uses a mid-level code in reporting all the cases. This may occur when the personnel does not fully understand which of the codes is accurate to use for each of the cases. Billing for a discharge instead of a transfer is also a noncompliance. This may occur when a patient is charged for a discharge from the hospital when he is instead transferred to another facility of the hospital e.g. a hospice or nursing center. An incorrect use of time to determine Evaluation and Management (E/M) code is also fraudulent. According to state guidelines, when counseling takes more than 51% of the encounter time may be used to choose the most accurate code. There are cases where the physician uses time to determine the code although the counseling rule is not applicable. Diagnosis-related group (DRG) creep is another case. This is an upcoming from the hospital’s end. It happens when the coders report diagnoses incorrectly cause the classification of DRG to be inflated. It may also occur that a patient is incorrectly recorded as an inpatient. This leads to noncompliance. An example could be when a patient attending dialysis is treated as an inpatient. Noncompliance also occurs when certain services are charged for are setting they are not provided in. there are specific services that can only be provided at the hospital facility. When these services are provided to outpatients, then coding them as services provided in the hospital is fraud.

Noncompliance should be reported in a systematic manner to eliminate health care fraud, and service abuse. The medical coders are responsible for reporting noncompliant issues to their employer, which can be done anonymously. First, the Medical Provider and Analysis Review (MedPAR) billing data is scrutinized to identify any coding malpractices. A comparative analysis is performed to measure the extent of variation, as not all discrepancies are evidence of fraudulent coding practices. Some may be to human errors leading to wrongful reimbursements for inpatient care. Therefore, the challenge of the Health Information Management (HIM) personnel is to identify the discrepancies, establish what the represented data says about the coding practices, and document situations leading to unforeseen variations. This can be achieved through installing a specific data monitoring system. Periodically, an audit is performed and suspicious findings should be reported for a fraud investigation.

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Coding Compliance Auditing

Internal auditing

To ensure that a hospital is coding compliant, the HIM should carry out regular monitoring and audit of the internal coding practices. He should examine the operations with respect to the institution’s safeguard and compliance controls. This enables the hospital to identify errors before submitting claims thus giving room for correction. It also identifies potential areas that need intensive review and corrective action. For example, if improper assignment of codes is noted, there might be need for a review of the coding procedures. To achieve this, the HIM should ensure that the institution’s procedures for coding are in line with the national standards. He should then monitor and audit internal coding following these set rules for coding. If a problem is noted, he should notify the affected personnel as well as audit the rest of the population to ensure that the problem is completely eliminated. Corrective and displinary measurers against those causing the problems should be taken according to the institution’s rules.

External auditing

Apart from internal audits, there may be need to contract an outside firm to audit the hospital. In such a case, the HIM should follow the following procedure

  • Review records to ascertain that there exists a coding problem, based on the set guideline the hospital uses in coding.
  • Notify the compliance committee if there is a problem and suggest need for an external body to review the problem.
  • Once review is approved by the appropriate body, he should notify all key players in coding compliance and prepare them for the audit. He should also expand the record thought to have a problem to a larger population to determine the true extent of the problem.
  • After the problem is determined, he should educate coders to obliterate the problem and revise coding procedures to prevent future problems.
  • He should notify the payers on the problem and consult the legal counsel on the same. In case of overpayment, he should notify the business office to effect a refund.
  • There is also need to repeat an audit after a while to ensure that the problem is completely eliminated.

What to do on receipt of documentation request

The initial key thing to do is to identify the individual or organization requesting for documentation. This can be done by identifying the contact phone numbers. There is also need to notify the agency’s legal officer as a safeguard. The next step is to ensure that the documentation is dully done by ensuring that it contains all needed information and that everything in the document including handwritten work is readable. Next is to ensure that anything send back to the requesting agency is not an original but a copy of the document. The facility should also ensure that it responds to any request within the stipulated time limit. Responses should also be sent through a trusted delivery system which is traceable is used. This ensures that the facility ascertains the time when the mail is delivered and to whom it is specifically delivered to.

How to Respond to a Formal Request for an Audit by an External Reviewer

First of all, it is the healthcare’s management role to ensure that it approves a program or charter for internal review. The healthcare organization should allow open access to files and persons that need to be addressed by the internal reviewer. The company should expect that the internal reviewer reports to the health board, so that the organization can also be given the chance to address its responsibilities. Whenever there are coding, documentation or provider claims from hotlines or other reporting systems, the organization should avail this to the internal auditor. After all, it is good practice for the organization to document and follow-up on such claims (Buchbinder & Shanks, 2016).

A healthcare organization should welcome the opportunity to work with an external reviewer, whether it is before, or after a potential malpractice has been identified. The external reviewer provides an objective evaluation of the risk produced and gives recommendations for executing a proactive corrective action for coding claims, documentation and provider claims. As it is an outsider perspective nature, an external review can encourage knowledge sharing and increasing awareness for good practices among health providers and coders. Coder training and documentation issues are other benefits of an external review process. Thus, while considering an external audit, the healthcare organization should choose one that gives an unbiased review, has expertise in risk evaluation, and performs the process under the direction of a legal counsel (Buchbinder & Shanks, 2016).

Responding to an Audit Result Showing Coding Practice Resulting in Overpayment

After the audit results shows a coding practice of overpayment, the organization should review all the appropriate policies and procedures including the billing manuals and coding guidelines. Additionally, a sample of records should be reviewed to determine whether the overpayment is an isolated case or the problem is widespread. Afterwards, interview with the relevant staff should be conducted to establish how the overpaid bill came about. Ultimately, the overpaid claim should be submitted to the fiscal intermediary.

Health Care Organizations can use the following measures to respond to audit results;

  • Increase the number of times it reviews payments;
  • Increase review of management and evaluation claims;
  • Overpayment retrieval should be carried out to increase the prepayment review numbers;
  • And finally, the organization should respond to overpayment through demand of more documentation from clients making claims.

Reporting coding noncompliance

In case of a situation where a coding procedure does not comply with national coding policies, the HIM should compile a documentation stating and supporting his stand on the situation. He should then report to his or her supervisor on the inappropriateness of the coding practice as well as it implications. The report should detail the situation explaining why it is a fraud by outlining clearly which national policies it infringes. He should also report the same to his or her department administrator as well as the CFO and the CEO. The HIM can then share the report the external stakeholder if he is reporting to any.


Buchbinder, S. B., & Shanks, N. H. (2016). Introduction to health care management. New York: Jones & Bartlett Publishers.

Fabrikant, R., Kalb, P. E., Bucy, P. H., & Hopson, M. D. (2016). Health care fraud: enforcement and compliance. New York: Law Journal Press.

Mikula, A. V., Abraham, S., & Townshend, G. (2016). Health care law: a practical guide. New York: LexisNexis.

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