AMARILLO, Texas — Most HME providers know the term "corporate compliance," but many do not appreciate what a proper compliance program can do for an organization, according to Clay Stribling. Done right, an effective program can prevent problems before they happen, or allow companies to respond quickly and address concerns before the FBI or OIG comes calling.
Stribling, president of HC Comply, does nothing but focus on how HME suppliers can implement and maintain effective compliance programs. Even if compliance were not mandatory, the Amarillo, Texas-based health care attorney and consultant believes the discipline instilled through a good program would lead to a healthier bottom line.
Do providers have a choice when it comes to compliance? The answer is a bit more nebulous than you might think.
"It is kind of an unsettled question at this point," said Stribling. "As a part of accreditation, providers are required to have policies and procedures that address fraud, waste and abuse, and they are required to have someone in their organization who coordinates those efforts. In my mind, that means compliance policies, because those are policies that are designed to reduce fraud."
The other part of the picture concerns health reform, also known as the Affordable Care Act (ACA), which is going to require all entities billing Medicare (except physicians) to have corporate compliance programs. There is currently no date for that deadline, but Stribling heard from a former CMS official that a timeline for compliance provisions would likely appear by the end of the year.
While the exact nature of the ACA's compliance requirement is unknown, Stribling advises providers to work on a compliance program in advance, since all manner of payers can and will ask to look at charts, operations and day-to-day business. "The best way to prevent them from finding something inappropriate is to be conducting that internal review continuously in your own business," counseled Stribling. "If someone comes in and says, 'We want to look at your CPAP files,' you should not be panicking. You should be saying, 'That is great because I audit my CPAP files every single quarter, and I know exactly what is in there.'"
Implementing a compliance program, taking an internal look at charts and operations and auditing marketing functions accomplishes several crucial things, Stribling said. "You know what they are going to find when you turn [your files] over, and when you find an error, you launch a training program and a corrective action for anything that you found that is a problem. Even if they do come and look at charts and find problems from three years ago, you can … show that you have a process in place for identifying and correcting these, and that can go a long way with any of the contractors in helping diffuse concerns about your company."
As a result, he said, "compliance programs can save you a good bit of money."
One thing is certain: The government will not stop its mission to audit and oversee the HME industry. One reason is that the effort often bears fruit.
"The fascinating thing about health care fraud investigations from the federal government standpoint is it is one of the few things the federal government does that is unbelievably cost-effective, and even profitable for the government," said Stribling.
"The data that I love to quote is several years old now, but in 2002 for every dollar the federal government spent of health care fraud enforcement, they got $28 in return. Recent numbers I have seen in past years show that it is between $12 and $16 in return. Still, it is something that the federal government spends money on and gets more money back."
Looking at the industry as a whole, Stribling said, "there are plenty of bad players out there that make it an attractive landscape for the federal government to investigate. I am not trying to paint with a broad brush and say that this industry is problematic, because I think that by and large the established players in this market are committed to doing things the right way. But, because there are players out there that are trying to get into this industry, profit through fraud, and get out, the federal government sees it as an industry that is ripe for enforcement.
"Companies need to be ready for scrutiny, even if they are doing things the right way," he continued. "The government is going to come in and kick the tires, and you need to know before they get there what they are going to find."