Type of paper: Essay

Topic: Conformity, Compliance, Doctor, Medicine, Committee, Education, Medicare, Actions

Pages: 5

Words: 1375

Published: 2020/12/04

Compliance plan

The Medicare practices willingly set forth the compliance program to enable individuals and small physicians’ practices in giving quality health care to the patients. The aim of the compliance plan is to reduce fraud, prevent abuses, and minimize wastages. The primary aim of the compliance plan for the individual and small physician practice is to detect, prevent, and find resolutions of the variances. Hence, the compliance plan of the individual will contain the eight elements that are in the compliance program of the medical practice.

Elements of the compliance plan

1. Commitment to compliance

A. Standard of conduct

B. Medical necessity
C. Billing
D. Reliance on standing orders

E. Compliance with applicable HHS Fraud Alerts

f. Marketing

G. Inducement

H. Retention documentation
2. Designation of a compliance committee
3. Conducting education and training programs
4. Communication
5. Disciplinary guidelines
6. Auditing and monitoring
7. Corrective Action
8. Response to the agent visit with the intentions of investigating abuse and fraud allegations

A. standards of conduct

The fundamental element in the compliance plan is the adherence that the plan compels every individual and small physician’s practices to follow. The plan compels Individuals and small physician practices to comply with the medical practices acts and duties with the standards of conducts. The compliance plan requires a thorough background investigation of individuals and small physician practices before they start to work with medical practices. The compliance plan is very strict in determining the individuals who are fit to practice in the medical field. For instance, individual with criminal records or professional licensure may be denied the chance to act under the compliance plan, as the probability of this people adhering to the medical standards is low. Under the standard conduct, all physicians and individuals must undergo a training in which they are required to participate. Failure to full participation will lead to disciplinary actions and termination of employment. Individuals should read and understand the content of the compliance programs and then sign that they have received the plan. Individuals will continue to receive periodic training to increase their compliance and duty relation. Failure to comply with the plan leads to sanction of that individual.

Medical necessity

Individuals and small physician practices are responsible for their actions in running tests and diagnosing patients. The Medicare only pays for the tests that meet the Medicare coverage Hence, the individuals and small physician practices must use the prudent ordering practices in claiming for payment. Physicians will make independent medical decisions about the patients' order when it comes to diagnosis and tests. Then a diagnosis will be submitted accompanied by documentation of the findings to support the medical necessity of the service.
The physician needs to know that the Medicare is not responsible for covering routine screening test. The physician should be aware that organ and disease related panels are billed only when the components are medically necessary. Then the physician will demand services that are believed to be appropriate for the patient treatment.
C. Billing
Tests that are billed are those that meet the Medicare health program. Such tests need authorization from an authorized physician and then submitted to the Medicare for correct identification. If the physician knowingly or intentionally up code the services that he offered then it would lead to termination of that physician. At such incidents, the physician needs to provide a documentation that supports the codes that he used based on the diagnosis and the medical findings.

Reliance on the standing orders

In complying with standing orders, physicians are allowed to extend the current course of treatment. In utilizing the standing order, individuals are expected to write down a fixed term of validity, renew the order when it expires if there is an indication of continued treatment.

Compliance with applicable HHS Fraud Alerts

Individual physician needs to comply with the relevant HHS fraud alerts. Failure to respect, the individual will face reasonable measure of action from the committee of conformity. Compliance is done to reduce future violations.


In marketing the Medicare practice, the Medicare sector is only interested in promoting fully informative honest and straightforward individual. Hence, for individual to stand the chance of promotion must meet the above qualities.


The physician needs to consider the interest of the patient when the issue of treatment service option or diagnostic arises. This is because the Medicare will not condone the provision of inducements to influence referrals.

Retention of documents

The Medicare will maintain all the documents that the state law may need and these records are kept for a proportionate period of seven years and above.

Designation of a compliance committee

The compliance plan designates the compliance committee to act /serve as coordinators of compliance activities.
Compliance Committee
The compliance committee is responsible for:
The committee of conformity is responsible for advising the officer and assists the director to implement the program as required.
It analyzes the practices of the regulatory environment, the risk areas, and the legal requirements that the regulation environment has to comply.

The committee assesses the existing procedures and policies in attempt to address the risk areas to incorporate the compliance plan.

The committee tries to promote compliance through working within the practices of the standard conduct.
The committee monitors and recommends the development of the internal systems in implementing standards policies and procedures.
The committee determines the best approach to promoting compliance plan through detection of any potential violations
Conducting adequate training and education
It is a requirement for the medical practice for all individuals and small physician practices to attend training when they are hired. The training includes the program requirement, private payors policies, state statutes, and corporate ethics. The education will dwell on commitments to compliance with the policies and legal requirements.
All the programs mentioned in the compliance plan will constitute the sessions of the training. For instance, the program of claim development, claim submission, coding requirement, and marketing will constitute the components of the training.

The primary education constitute

Government and private payers as remuneration principles
General constraints of individual to receive or pay inducements to anti-back referrals
Right translation of reported diagnosis
Only billing for tests and services ordered, conducted and narrated
Communication allows for mutual existence and relation between the government and the employees. Developing perfect lines of communication creates an avenue for individuals and small physician practices to seek clarification from the committee whenever there is an element of confusion. There is the need to report any conduct that tend to violate the compliance of the program to the compliance committee. After the reporting of any misconduct that violates the compliance, then the compliance committee will not act on the mere reports but rather investigate the matter to determine its truth or accuracy.

Then the compliance committee will work with legal counsel to acquire guidance on how to handle legal and management issues.

Disciplinary guidelines
Individuals and small physician practices will be held responsible for failure to comply with the laws and regulations of the applicable standards. Managers and supervisors, on the other hand, will be held liable for the foreseeable failure of the entire compliance plan. However, if the deviation occurred as a result of legitimate reasons with the viable reason, then the disciplinary committee or the managers may find a reason to reduce the disciplinary actions. Warranted disciplinary actions should be promoted and enforced according to the reported disciplinary actions. Actions to be taken might be the following:

Adjournment of the matter

Counseling the physician or individual
Giving the individual a warning through a letter
Putting the individual under the supervision
The individual may be suspended or the clinical advantages of this physician reduced
As well, the individual’s employment might be terminated
In addition, the duties assigned to such employees may be modified, or their salaries and compensation reduced.
The chief officer has authority to suspend the clinical privileges of individuals violates the compliance of the program.
Auditing and monitoring
A compliance plan progressively evaluates the compliance standards when it comes to holding individuals and small physician’s practices accountable. To ensure the accuracy, the program tries to access whether the individuals and small physician practices give the proper claim for remuneration and whether they are responsible for carrying out their duties as designated. It is necessary to audit the records at least annually or even semi-annually. Auditing and monitoring create accuracy in coding, billing documentation of claims.

Corrective action

Individuals and small physician practices need to comply with the plan about the applicable statute laws. Failure of compliance leads to the violation of individuals and small physician practice through their misconduct. For accountability, they will be reported by the compliance committee to the office of inspector general. However, the committee must have enough evidence of a violation of compliance with reporting.

Response to the agent visit for the purpose of the investigation

Individuals are visited agent for the purpose of further investigations of failure to comply with the plan. In the event the individuals are faced with, such circumstances, there is the need to request for search warrant prior any investigation. It is important for the individuals and small physician practices to record the names of the search agents with the agencies they represent. They should be aware that they have a right to ask the agents to delay the search until all patients are served then accompany the search agent during the search. Finally, if necessary, the manager of the small physician may brief the employees the employees after the search if at all they were interviewed.


Becker, J. M. (2010). A guide to coding compliance. Clifton Park, NY: Delmar Cengage Learning
Uselton, J. P., Kienle, P. C., Murdaugh, L. B., Coe, C. P., Joint Commission., & American Society of Health-System Pharmacists. (2010). Assuring continued compliance with Joint Commission Standard: A pharmacy guide. Bethesda, Md: American Society of Health-System Pharmacists
Mihajlovic-Madzarevic, V. (2010). Clinical trials audit preparation: A guide for good clinical practice (GCP) inspections. Hoboken, N.J: Wiley
Admnistration, H. C. (2000). OIG Compliance Programs for Individual and Small Group Physician's Practice. Federal Register.

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WePapers. (2020, December, 04) Compliance Plan Essay Samples. Retrieved April 23, 2024, from https://www.wepapers.com/samples/compliance-plan-essay-samples/
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Compliance Plan Essay Samples. Free Essay Examples - WePapers.com. https://www.wepapers.com/samples/compliance-plan-essay-samples/. Published Dec 04, 2020. Accessed April 23, 2024.

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