In large cities like Dallas, hospitals are one of the main targets by the federal government. This is because the healthcare system is highly prone to fraud, waste, and abuse. Hospitals should prioritize compliance, and if an investigation or audit is launched against them, they should be ready to defend.
Hospitals are one of the most burdened institutions in the U.S. They must respond suitably depending on the degree of urgency, diagnose illnesses appropriately, and provide the right treatment. In addition to all these, they must also establish exhaustive procedures and policies to ensure they’re compliant with the relevant laws and regulations as established by the federal government.
Compliance is required in virtually all aspects of a hospital’s operations – from Medicare billing, patient records, worker characterization, to contracts with various personnel. If a hospital doesn’t comply with all the established laws and regulations, it risks being held liable, and auditors or investigators will ensure everyone involved will account for their mistakes.
Dallas, TX Hospital Compliance and Audit Defense Attorneys
Here at The Criminal Defense Firm, we represent Dallas hospitals to ensure they’re compliant with their obligations, and if an audit is launched against them, we can also help them defend. Our team of highly qualified healthcare lawyers and compliance consultants has many years of experience, having previously worked as federal agents and prosecutors in the U.S. Department of Justice (DOJ), U.S. Department of Justice (DOJ), Drug Enforcement Administration (DEA), Department of Health and Human Services (DHHS), and others.
We have our headquarters in Dallas, but we offer our services across the country. We have successfully helped Texas hospitals and other healthcare providers nationwide avoid liability for serious compliance mistakes.
What Makes an Effective Hospital Compliance Program? Here are 10 Key Elements
For hospitals, there are various compliance obligations that they should keenly attend to and implement correctly. Our attorneys and consultants offer exceptional representation when it comes to compliance, and they work hand in hand with hospital administrators, executives, and other personnel to customize procedures and policies that address the specific compliance needs of each healthcare institution. That way, a hospital can avoid related risks.
The following are the 10 key elements of a well-defined and efficient hospital compliance program. In each of these elements, we custom-tailor our services to ensure protection for our clients and make sure they’re not held liable in case of an investigation or audit.
1. Proper Documentation of the Compliance Program
A hospital should document its compliance programs in the form of comprehensive procedures and policies. These procedures and policies should exhaustively address all the relevant compliance matters, and they must be properly written for easy and effective implementation depending on a hospital’s unique organization and structure. What this means is that there isn’t such a thing as a ‘standard’ compliance program. If the program isn’t tailored to each specific hospital, then it may not offer the required protection.
2. Employment and Independent Contractor Agreements
One aspect that may present challenges for hospitals is employment. Proper classification of everyone involved in the hospital as employees or independent contractors is of great importance. If a hospital doesn’t classify everyone appropriately, then it risks being held accountable by the Texas comptroller and the Internal Revenue Service (IRS). Apart from proper classification, a hospital should also ensure that the contracts it has with employees and independent contractors have enough protection measures to reduce their risks of being held liable for any mistakes.
3. Personnel Training and Education
The required compliance procedures and policies have been formulated; the next step is implementing them. In general, the process of implementation starts with offering training and education to all the relevant individuals. The personnel responsible for training and educating should customize everything depending on employees’ and contractors’ specific duties. And after everyone has completed the training and education process, proper also documentation is vital.
4. Hospital Marketing Compliance
One of the most overlooked aspects of hospital compliance is marketing. However, it’s also an area that tends to hold great risks. When engaging in marketing efforts, hospitals should ensure they’re not putting themselves at the risk of being accused of utilizing program-reimbursed finances to pay for Medicaid, Tricare, Medicare, or DOL patient leads. It’s possible for hospitals to advertise their services legally, but for that to happen, everyone involved should extensively understand the applicable laws and regulations.
5. Third-Party Contracting
Apart from employment and independent contractor agreements, a hospital should also handle compliance-related matters when contracting with suppliers and other 3rd parties. One area that hospitals should be particularly concerned with is contractual agreements with 3rd party billing service providers. However, the institution should draft all contracts with enough safeguards depending on its individual potential risks.
6. Billing and Coding Compliance
Hospitals and other health institutions should be greatly concerned about compliance relating to billing and coding. Billing Tricare, Medicaid, Medicare, or the DOL illegally can lead to a reduction or withholding of funds, program exclusion, civil monetary penalties (CMP), and many other penalties. This can happen no matter whether your hospital has hired a 3rd party billing service provider. Dallas and nationwide hospitals should not only implement the right billing and coding compliance practices, but they should also document everything as proof of their efforts to abide by the set laws and regulations.
7. Internal Compliance Violation Reporting
If one of the personnel in your hospital makes a compliance mistake, you should know it as soon as possible. One thing you shouldn’t miss in your hospital’s compliance program is a set of procedures indicating how to report compliance mistakes anonymously or suspected violations. There should be well-established reporting channels with a specific command chain, and hospital executives should be ready to act fast once they realize a potential violation.
8. Responding to a Compliance Violation
A hospital’s compliance program should also comprise of procedures on how to respond to a violation. Depending on the violation, the response can be internal and external. Internal response is handling the violation within the institution and disciplining the associated personnel suitably. In external response, the administrators determine whether self-reporting is needed. Responding to any issues promptly is critical – delayed measures may create even more problems than the violation itself.
9. Recordkeeping and Ongoing Compliance Documentation
For efficient defense against an audit or investigation, a hospital should have all the relevant documents on hand. The pieces of documentation should comprise of the hospital’s procedures and policies, as well as documents showing ongoing compliance efforts. What this means is that these institutions should consistently generate records as time passes. They should also layout procedures to organize the records properly for easy retrieving when necessary.
10. Preparing for Audit Defense
Apart from documenting and preserving records of compliance efforts, a hospital should also take steps to prepare itself in case of an audit or investigation. These preparation measures should include well-defined defense methods, personnel training on how to conduct themselves when auditors talk to them, and a step by step plan to avoid mistakes and mitigate the chances of being held liable.
12 Compliance Mistakes that May Lead to Hospital Audits and Investigations
When auditors or investigators assess a hospital’s compliance documents, they’re looking for various mistakes or violations. When they find any, they’ll be forced to investigate further. While a hospital may be prepared to defend itself, avoiding liability completely may be challenging when investigators find mistakes.
As defense attorneys and consultants, we at The Criminal Defense Firm have handled lots of situations for hospitals and other healthcare providers. Here are the 12 most common and high-risk mistakes we have noticed among different providers:
- Patient disregard
- Involvement in fake contracts
- Using illegal marketing practices
- Improper classification of employees and independent contractors
- Failure to establish medical need
- Telemedicine violations
- Underrating insurance audits
- Lack of oversight and contract protections
- No demonstration of compliance efforts
- Believing that having HIPAA (Health Insurance Portability and Accountability Act) policies means compliance
- Failure to get legal protections in billing and coding contracts
- Improper documentation
We Represent Dallas and Nationwide Hospitals in Audits and Investigations Concerning Private Insurance, RAC, UPIC, MAC, and Others
Hospital compliance audits and investigations come in various forms. When it comes to Medicare, fee-for-service contractors who work with the CMS (Centers for Medicare and Medicaid Services) – including Recovery Audit Contractors (RACs), Unified Program Integrity Contractors (UPICs), and Medicare Administrative Contractors (MACs) – are very active and aggressive in pursuing recoupments because they’re paid depending on the recovered alleged overpayments. DOL and Tricare auditors are also similar in aggressiveness, and private insurance service providers have extreme rights when it comes to auditing their hospital contracts.
If you’re an administrator or executive and your hospital is experiencing an audit, you need to keep in mind several facts. One, the audit can’t resolve itself; if you don’t act as necessary, the auditing individuals will always find reasons to recoup funds, and appealing to the audit’s outcome can be a long, challenging, and costly process. Two, proactive measures to ensure you’re not held liable are crucial – they can save a lot of time and effort as well as reduce the chances and risks of future audits. Three, even though a hospital has been found with compliance mistakes, hiring an experienced defense team is an excellent choice to avoid and minimize liability.
The Criminal Defense Firm Law Firm – Helping Dallas and Nationwide Hospitals With their Compliance and Audit Matters
Is your hospital’s compliance program outdated or inadequate? Or is your hospital facing an audit or investigation? Get in touch with The Criminal Defense Firm to talk to an experienced compliance and audit attorney and learn how they can help. We also encourage you to contact us if you have any questions regarding hospital compliance. You can either call us via 214-817-2053 or schedule a free online consultation here.