This compliance program guidance is intended to assist individual and small group physician practices in developing and implementing internal controls and procedures that promote adherence to statutes and regulations applicable to the Federal health care programs and private insurance program requirements.
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TABLE OF CONTENTS
- Introduction
- Benefits of a compliance program
- Application of compliance pregram guidance
- The Difference Between Fraudulent and "Erroneous" Claims to Federal Health Preogams
- Compliance Program Elements
- The Seven Basic Compliance Elements
- Written Polocies and Procedures
- Code of Conduct
- Policies and Procedures
- Specific Risk Areas
- Coding and Billing
- Reasonable and Necessary Services
- Documentation
- Medical Record Documentation
- HCFA 1500 Form
- Kickbacks, Inducements and Self-Referrals
- Retention of Records
- Designation of a Compliance Officer/Contact
- Conduction Effective Training and Education
- Compliance Training
- Coding and Billing Training
- Format of the Training Program
- Continuing Education on Compliance Issues
- Developing Effective Lines of Communication
- Auditing and Monitoring
- Policies and Procedures
- Claims Submission Audit
- Enforcing Standards Through Well-Publicized Disciplinaty Guidelines
- Responding to Detected Offenses and Developing Corrective Action Initiatives
- Conclusion
APPENDIX A: ADDITIONAL RISK AREAS
I. Reasonable and Necessary Services
A. Local Medical Review Policy
B. Advanced Beneficiary Notices
C. Physician Liability for Certifications in the Provision of Medical Equipment and Supplies and Home Health Services
D. Billing for Non-covered Services as if Covered
II. Physician Relationships with Hospitals
A. The Physician Role in The Patient Anti-Dumping Statute
B. Teaching Physicians
C. Gainsharing Arrangements and Civil Monetary Penalties forHospital Payments to Physicians to Reduce or Limit Services to Beneficiaries
III. Physician Billing Practices
A. Third-Party Billing Services
B. Billing Practices by Non-Participating Physicians
C. Professional Courtesy
IV. Other Risk Areas
A. Rental of Space in Physician Offices by Persons or Entities to Which Physicians Refer
B. Unlawful Advertising
APPENDIX B: CRIMINAL STATUTES
I. Health Care Fraud (18 U.S.C. 1347)
II. Theft or Embezzlement in Connection with Health Care (18 U.S.C. 669)
III. False Statements Relating to Health Care Matters (18 U.S.C. 1035)
IV. Obstruction of Criminal Investigations of Health Care Offenses (18 U.S.C. 1518)
V. Mail and Wire Fraud (18 U.S.C. 1341, 1343)
VI. Criminal Penalties for Acts Involving Federal Health Care Programs (42 U.S.C. 1320a-7b)
APPENDIX C: CIVIL AND ADMINISTRATIVE STATUTES
I. The False Claims Act (31 U.S.C. 3729-3733)
II. Civil Monetary Penalties Law (42 U.S.C. 1320a-7a)
III. Limitations on Certain Physician Referrals ("Stark Laws") (42 U.S.C. 1395nn)
IV. Exclusion of Certain Individuals and Entities From Participation in Medicare and State Health Care Programs (42 U.S.C. 1320a-7)
APPENDIX D: OIG-HHS CONTACT INFORMATION
I. OIG Hotline Number
II. Provider Self-Disclosure Protocol
III. Advisory Opinion Requests
APPENDIX E: CARRIER CONTACT INFORMATION
APPENDIX F: INTERNET RESOURCES 
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