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The Need for Creating a Culture of Compliance

Original story posted on: April 22, 2019

Understanding why a culture of compliance in coding and documentation is so important.

Compliance is a large part of our duties in healthcare. It is especially true for coding. With so many regulations, the audit atmosphere and payment nightmares, quite simply we are a moving target. For those of us in the compliance world, we can recite the seven elements of an effective compliance plan in our sleep.

  1. Implementing written policies, procedures and standards of conduct. 
  2. Designating a compliance officer and compliance committee. 
  3. Conducting effective training and education. 
  4. Developing effective lines of communication. 
  5. Conducting internal monitoring and auditing. 
  6. Enforcing standards through well-publicized disciplinary guidelines. 
  7. Responding promptly to detected offenses and undertaking corrective action.

It’s easy for us to set policies and procedures. We are so used to following all of the coding rules and regulations that it is almost second nature to us. But beyond the technicalities, are we creating a culture of compliance in our organizations? It’s not enough for us to simply have rules and rulers.

Culture is extremely important in our practices. Good culture promotes doing the right thing without fear of retribution. It’s empowering our employees to be able to freely express concerns and have open conversations regarding those same concerns. We must go beyond the black and white rules to create an environment where our teams can help us steer the course.

According to the book, “Five Dysfunctions of Teams” by Patrick Lencioni, there are common issues that tear down our teams. As we discussed earlier, building trust will remove these dysfunctions and allow us to create the positive tension we need for improvements.

  1. Absence of trust
  2. Fear of conflict
  3. Lack of commitment
  4. Avoidance of accountability
  5. Inattention to results

We need to make sure we work on these five items so that we have a good strong culture in our offices. In 2017 more than $260,000,000 was paid out to whistleblowers or those identifying fraud in healthcare. A disgruntled employee can cause major damage to a practice or facility. Even if in the long run if your practice is targeted by a whistleblower and you prove yourself innocent it takes years to resolve via a ton of work and money. In fact, many providers found in this situation simply throw in the towel due to the costs and stress of defending. Not to mention the negative press.

The best thing you can do is not to put yourself in that situation. While you can’t stop reporting or control the actions of others you can protect yourself by being proactive and creating a culture of compliance in your practice.  For example:

  • Be sure to keep compliant billing policies
  • Don’t over-regulate
  • Make sure the staff knows the difference between medical necessity and payer policies
  • Make sure your staff is educated to fully explain to a patient a non-covered service and why they are responsible for payment
  • When a new policy is developed train the entire staff
  • Set up a reporting mechanism where employees can report issues anonymously
  • Take complaints seriously and take action consistently when warranted
  • Do a yearly compliance walk-through and educate staff on findings and resolutions

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has some great resources out there that offer free training and help. They also offer these tips for creating a culture of compliance:

  1. Make compliance plans a priority now. 
  2. Know your fraud and abuse risk areas. 
  3. Manage your financial relationships. 
  4. Just because your competitor is doing something doesn’t mean you can or should. Call 1-800-HHS-TIPS to report suspect practices. 
  5. When in doubt, ask for help.

At the end of the day, you need enforceable policies that are consistent and monitored. Be sure to take all complaints seriously and act on those without retaliation. Make sure your staff feels empowered enough to speak freely. It’s these small steps that can help you build the culture necessary in your practice.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.

Rhonda Buckholtz is the vice president of practice optimization for Eye Care Leaders. She has more than 25 years of experience in healthcare, working in the management, reimbursement, billing, and coding sectors, in addition to being an instructor. She is a past co-chair for the WEDI ICD-10 Implementation Workgroup, Advanced Payment Models Workgroup and has provided testimony ongoing for ICD-10 and standardization of data for NCVHS. Rhonda spends her time on practice optimization for Eye Care Leaders by providing transformational services and revenue integrity for Ophthalmology practices. She was instrumental in developing the Certified Ophthalmology Professional Coder (COPC) exam and curriculum for the AAPC. Rhonda is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

Latest from Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC

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