Per the Merriam-Webster’s Learner’s Dictionary, the simple definition of compliance is “the act or process of doing what you have been asked or ordered to do: the act or process of complying”.

The Affordable Care Act (ACA) requires a mandatory compliance program be put into effect for any healthcare provider enrolled with Medicare and Medicaid.  In the event that you are not a provider for Medicare and/or Medicaid, it is still highly recommended that you implement a compliance program. A healthcare entity’s main focus in compliance is to ensure policies and procedures are in place and enforced, in addition to the implementation of preventative measures to avoid potential problems in the future (preventing, identifying, and mitigating risks).

POST ACUTE CARE: A MODEL DELIVERY SYSTEM - GET THE COMPLIMENTARY EBOOK!

An Effective Compliance Program

Having an effective compliance program in place is the best way to identify internal issues/risks, implement preventive measures and mitigate the risks.  For example, having a compliance program in place is beneficial during a survey. Surveyors are more apt to treat a facility/center less harshly if the facility has a compliance program, and if they have already self- identified the issue and have a plan to correct.

An example of a much-needed area of compliance is the Triple Check Process, an internal system for pre-billing claims review.  A review of the claims and all associated documentation prior to billing should include: the claims, therapy logs, therapy orders and Therapy Certs/Recerts including dates and signatures, skilled services Certs/Recerts including Physician signature and dates, diagnosis, MDS, Nursing orders, documentation of skilled services, plan of care, and any other areas required for the claim submission based on payer requirements.  

This type of self-audit can uncover several areas that the facility/center could identify as an area that they need to improve upon - in which a Quality Assurance Performance Improvement (QAPI) Plan could be implemented. Documentation is often found to be one of the main areas of concern and is highly scrutinized, often leading to review for appropriateness and medical necessity when records are reviewed.

There is a common saying, “if it isn’t documented, it didn’t happen”. Yet too often, we find that documentation is either omitted or lacks the requirements to substantiate what is required. An example is the skilled services delivered by nursing in a skilled nursing facility; often the nursing staff will focus on stating the resident is receiving therapy services (e.g., physical, occupational or speech/ language) but neglect the reason why and how it impacts the resident clinically. Worse yet, there are times that the nursing documentation contradicts what is being documented by the therapists.

Compliance with policies, procedures, and standards within the facility and/or billing entity are only one part of the equation. We are also subject to state and federal mandates.  Identifying and keeping up with compliance practices, including best practices in your profession are vital to your success. Therefore, identifying a Compliance Officer and implementing a compliance plan are the first steps to meeting the ACA mandatory requirement and mitigating your facility/center risks.