QA & Medicare Compliance, Physician Provider Review &
Voluntary Program, Kentucky (US)
Client Issue: A physician provider was raided by agents for the Federal Bureau of Investigation (FBI) on behalf of the US Dept of Justice (DOJ) via a qui tam or "whistleblower suit" initiated by what the client felt was a former disgruntled employee. Subsequently, the client underwent investigation for fraudulent filing of Medicare claims by the Dept of Justice. The client requested a voluntary physician compliance program be initiated for the medical practice.
Solution: Initiated a voluntary physician compliance program, conducted baseline coding/billing & practice audit, developed compliance plan, policies & procedures, conducted staff & multiple physician compliance training. Initiated internal quarterly audit tool for practice ongoing use. Determined/conducted additional staff education required based on workplace & labour law requirements. Focused on practice communication strategies & worked with leadership & management staff of practice on leadership/management strategies for the practice. Trained internal compliance officer & followed up on quarterly basis. Continued to focus on any changes in standards & compliance issues & function as external compliance resource. Worked with client's civil & criminal attorneys to advise compliance program status.
Outcome: Successful implementation & ongoing organisational voluntary physician compliance program. Quarterly audits have been effective & opportunities for additional practice education continue.