Ugh, Healthcare Compliance.

compliance planBy: Jacqueline Bain

I had a law school professor who repeatedly referred to his class as “Doom at Noon.”  The topic was dry, the cases were boring and, if not for the professor himself, the class would have been unbearable. I think of that, all these years later, every time I have to counsel a client on a topic that makes his or her eyes glaze over, like healthcare compliance.

Compliance means that you’re operating within the bounds of law. Sure, it sounds boring, but it’s a giant undertaking for any business, and especially for one so regulated as healthcare. Over the last three decades, the Department of Health and Human Services’ Office of the Inspector General has urged the private healthcare community in to take steps to combat fraudulent conduct and prevent the submission of erroneous claims.Continue reading

Employee Files & What to Do With Them

By: Valery Bond, RHIT

As healthcare professionals, we take pride and care in the detail in maintaining our employee files.  Certain items must be separated from the others, files securely locked and out of reach from co-workers hands.  Personnel’s personal information must be protected.  We all know these things and probably already have a procedure in place for compliance.

Whether your facility has been deemed accredited (Joint Commission, for example) or just starting up, employee files must be maintained, reviewed, audited, and kept according to retention requirements.  Knowing which laws apply aids in keeping your business compliant.  For example, pursuant to ERISA laws, there is no specific time period to maintain records that reflect age, marital status and/or service records.  The Social Security Acts states that employees’ social security numbers must be kept four years from the tax due date or payment of tax, whichever is later.  So, there’s a lot of tracking going on.Continue reading

Healthcare Compliance: Understanding ZPIC Audits

By: Susan St. John

So, you’ve received a letter from the Zone Program Integrity Contractor or “ZPIC” to review for the accuracy and justification of services reimbursed by the Medicare program. In other words, a dreaded ZPIC Audit or ZPIC Investigation. Now What?!

First, remain calm. Chances are an audit by ZPIC will go well if you have been diligent in completing patients’ medical records, justifying medical necessity, and your billing is accurate and well supported by the patients’ medical records. Even if errors are discovered, most errors do not represent fraud, that is, the errors were not committed knowingly, willfully and intentionally. Still, a ZPIC audit can be daunting and if Medicare has noticed a pattern of billing that it considers suspect, or there has been a complaint against you, the ZPIC audit will be rigorous, and often adversarial. The ZPIC’s job is to protect the program from potential fraud. It will conduct data analysis, including statistical outliers within a well-defined group, or other analysis to detect patterns within claims or groups of claims that might suggest improper billing. Data analysis can be undertaken as part of a general review of claims pre or post submission, or in response to information about specific problems arising from complaints, provider or beneficiary input, fraud alerts, CMS reports, Medicare Area Contractors, or independent governmental or nongovernmental agencies.Continue reading

Residential Substance Abuse Treatment & Life Safety Code

By: Valery Bond, RHIT

Did you know as a residential addiction substance abuse treatment provider, your facility must know what is, and what is not, above your ceiling tiles?  Does your facility have a “No Smoking” sign at the main entrance?  Do you know which way the doors are supposed to close?  Want to grow your business?  Plan on expanding?  You will need an ILSM (Interim Life Safety Measure) completed; and, the ILSM must include an infection control acknowledgment.

The Bottom Line About ILSM for Substance Abuse Treatment

In simplicity, buildings serving patients must comply with the NFPA 101 (2012 edition) Life Safety Code.  Has your substance abuse treatment organization identified a Safety Officer?  Has the Safety Officer identified Life Safety Code problems?  If your answer is “No” to these two basic questions, it may be time for your practice to implement a Life Safety program.

Known as “Minimum Fire Safety Standards for Residential Alcohol and Drug Abuse Treatment and Prevention Programs, mental Health Residential Treatment Facilities and Crisis Stabilization Units”, this rule chapter must be applied and adhered to in all 24 hour, 7 day per week healthcare facilities, just like a traditional hospital.Continue reading

Healthcare Business Operations: Non-Profit Regulations for the Rehab Industry

By: Shobha Lizaso

There has been a growing trend in the substance abuse rehabilitation industry to provide services through a non-profit, tax-exempt organization. Unfortunately, there is also a growing trend relating to IRS audits of non-profits. An audit by the IRS can yield many negative outcomes, including the revocation of a treatment center’s tax exempt status and fines imposed on the organization and/or its Directors when the non-profit fails to operate within the rules applicable to 501(c)3 non-profit organizations.

A non-profit may be able to fly under the IRS’s radar for a few years, but as the years pass, the chances that non-profit non-compliance will be caught by the IRS grows exponentially.  To protect your non-profit, please follow some of these basic rules:Continue reading

NonProfit Compliance: Conflicts of Interest Issues Can be Poison

Charity jar
Charity jar

By: Shobha Lizaso

You have a cause that you are passionate about. You have the drive and motivation to put your time and effort behind that cause. You have the dedication to use all of the aforementioned to create a 501(c)3 nonprofit organization.  However, once you create the organization, you must also be diligent in protecting your organization’s tax-exempt status.

Like most people who start a non-profit organization, your focus and energy is probably directed towards serving the community rather than performing internal compliance checkups. However, you cannot serve your target community well if your nonprofit is not run in a manner that is compliant with the law.

What happens when the IRS revokes your organization’s nonprofit status? Here are some examples:Continue reading