Maintaining compliance in a medical office is one of the most significant challenges that office managers face. With new regulations coming down the pipe, new employees to train, and policies to implement, it can be unnerving to stay on top of it all. To avoid healthcare fraud and abuse in the practice, the medical office manager must be knowledgeable and current with compliance laws and be equipped to manage issues when they arise.

All medical providers are required to establish a compliance program as a condition of enrollment in Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). Best practices for compliance in the medical office include establishing procedures based on current guidelines, documenting them, and providing training for everyone working in the practice.

If an incident occurs, you must document it, check it against procedures in place, and follow the proper protocols for reporting. For example, under the Affordable Care Act, a provider has a maximum of 60 days to report and return overpayments from Medicare and other federal health programs, even if the overpayment was caused by an error. Failure to report can result in civil charges and prosecution under the False Claims Act.

Common Medical Compliance Guidelines in a Medical Office:

• Health Insurance and Portability Act (HIPAA)
• Occupational Safety and Health Administration (OSHA)
• Medicare’s Quality Payment Programs: MIPS, MACRA, APMs
• Office of the Inspector General 7-step Compliance Program
• Medical identity theft
• Healthcare fraud and abuse
• Risk management guidelines for patient care and safety

HIPAA Compliance & Your Medical Practice
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Common Areas of Risk:

• Billing for a service or item that was not provided
• Submitting a bill to Medicare with the wrong provider identification number
• Failure to document policies and procedures for a breach of healthcare information
• Sharing unauthorized medical information without written patient consent
• Failure to provide OSHA training for all employees
• Providing a service that is not medically necessary or that does not meet professionally recognized standards
• Inflating fee for services for Medicare recipient

Stay Ahead of Medical Office Issues

The medical office manager role is complex. Several key compliance areas require in-depth knowledge of guidelines and a plan to manage successfully. Download the ebook Best Practices For Medical Administration for insights on practice, personnel, and financial management. Learn the steps to take to ensure you stay on top of and ahead of medical office issues.