May 30, 2024
Apr 15, 2025
Written By Elizabeth Cifers
Does thinking about compliance cause you stress? Maybe you don’t know the laws and regulations governing your retina practice or group. Or perhaps you have a sneaking suspicion that mistakes are being made on your watch.
You don’t know what you don’t know. It’s one of the reasons so much effort has gone into developing information to create compliance programs that effectively help mitigate the risk of noncompliance.
The following compliance program elements are an overview of the U.S. Department of Health and Human Services Office of Inspector General’s (HHS OIG’s) General Compliance Program Guidance.¹ While the application may vary from group to group, these elements offer an excellent general roadmap for compliance best practices.
The content of this article does not constitute legal advice. Consult your attorney to discuss your concerns if you suspect legal violation(s) at your practice.
An effective compliance program includes a written code of conduct and compliance-specific policies and procedures. A code of conduct relays your retina practice's mission, goals, and ethical requirements and states your commitment to legal and regulatory compliance. Compliance-specific policies and procedures should outline the implementation of your compliance program.
The compliance program and the general policies and procedure documents should be easily accessible to everyone on your staff. They should be reviewed regularly, at least annually, for potential updates against current laws and regulations.
Leadership and oversight of your compliance program involve practice leadership, your board of directors (if you have one), a compliance officer, and a compliance committee. Smaller practices may designate a senior staff member as the compliance officer. This person should have the authority to interact with the practice as an equal to the other senior leadership. Additionally, the compliance officer should have good judgment, integrity, and assertiveness, to name a few of the necessary qualities.
Practice owners, leaders, and boards are ultimately responsible for compliance at their practices and should be actively involved in overseeing their compliance programs. Leadership engagement in compliance sets the tone for the practice.
The compliance officer’s role is to implement the compliance program, chair any compliance committee, and periodically report on compliance activities to practice leadership. The committee’s role is to support the compliance officer. The committee should meet quarterly to assess the compliance program's effectiveness.
The compliance officer should not report to legal, financial, or billing divisions but to the board or president, as appropriate. The compliance officer may report to the practice owners or board in smaller practices. The compliance committee should be composed of leaders from the various functions of your retina practice.
Compliance training and education should be completed annually by all levels of your practice (owners, leaders, and boards included), and updates should be provided as laws and regulations change. In addition to formal training and education, look for opportunities to educate throughout the year, such as in practice newsletters or during staff meetings.
Your compliance officer should develop the training and education with the committee's support. In addition to general laws and regulations, consider including compliance risks specific to your retina practice in your training and education—risk areas identified in assessments, audits, or investigations.
Note: As part of your compliance efforts, ensure licensed and certified personnel complete any training and education mandated by their licensing or certifying authority.
Anyone at your retina practice should feel empowered to report concerns of compliance violations directly to your compliance officer. Publish ways to report concerns in visible locations, such as a break room, and include anonymous reporting methods. Develop confidentiality and nonretaliation policies. Information shared with others (board or compliance committee) should be on a ‘need to know’ basis and not shared indiscriminately. The compliance officer should maintain a log of reports and actions taken.
Robust compliance programs have consequences for violations and incentives for performance and innovation. Depending on the violation, the consequences may be punitive, educational, or non-punitive, such as remediation. What’s important is that the consequences are fair, equitable, consistent, and communicated before any potential offense. Additionally, practice or group leaders are encouraged to devote thought and effort to brainstorming creative incentives for large and small contributions to compliance.
Risk management starts with annual risk assessments, from which a compliance work plan can be developed for auditing and monitoring prioritized risks. If your retina practice receives Federal monies, for example, from the Centers for Medicare and Medicaid Services (CMS), regular assessments are advised as part of compliance. Data analytics can be used to identify risks.
Audits should be performed at least annually, and additional audits should be performed as needed. They can be conducted by trained staff or an expert third party. Risk monitoring includes routine review of the List of Excluded Individuals/Entities (LEIE) and State Medicaid program exclusion lists to ensure your practice has not employed, contracted, or made agreements with an excluded individual or entity.
The first step is an internal investigation if a compliance violation is suspected. Suspected violations typically require further inquiry before a determination of the course of action can be made. Depending on the nature of the possible issue, you may need to coordinate with your attorney for potential Government reporting. If a violation is found, prompt action is best. Maintain a record of the investigation, including documents, notes, and a description of your process.
Some potential outcomes may be refunding overpayments, educational or disciplinary measures, or changing policies or procedures to prevent future improper conduct. If an overpayment from your Medicare Administrative Contractor (MAC) is found, Medicare requires a refund of overpayments within 60 days.1
Once you have an effective compliance program, retina practice managers can breathe easier with a roadmap to follow. Effective compliance programs feature risk management activities, open lines of communication, and engaged leadership, to name a few key elements. Detailed adherence to HHS OIG’s general guidance on compliance can spell compliance success for your practice or group.1
Are you looking for a partner to help implement compliance activities at your retina practice or group? Elizabeth Cifers is certified in Healthcare Compliance and has decades of experience in one of the greatest risk areas for noncompliance: medical coding and billing. She offers consulting, risk assessments, chart audits, training, and more. Book a free consultation with Elizabeth here.
Sources:
1U.S. Department of Health and Human Services Office of Inspector General (November 2023). General Compliance Program Guidance. https://oig.hhs.gov/documents/compliance-guidance/1135/HHS-OIG-GCPG-2023.pdf
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