Medical Records and the Law

434 CHAPTER 12: RISK MANAGEMENT AND QUALITY MANAGEMENT• Reinforcement of statutes and regulations addressing claim developmentand submission• Guidelines for compliance with medical necessity standards, antikickbackand antireferral statutes• Procedures for proper outpatient coding, admissions and discharges,and supplemental payment considerations (such as improper claimsfor clinical trials and abuse of diagnosis related group [DRG] outlierpayments) 18• A mechanism for reviewing whether the organization is properly reportingbad debts to Medicare• Procedures for providing timely and accurate reporting of Medicareand other federal healthcare program credit balances 19Similar components are contained in the OIG guidelines for physiciansand small group practices; however, unlike the hospital guidelines,these guidelines do not necessitate the implementation of a fullscale compliance program. Instead, the OIG emphasizes a step by stepapproach to follow in recognition of the unique fiscal and staffing constraintsfaced by such physician practices. 20A healthcare organization’s corporate compliance plan should betargeted to the needs of that particular organization.The healthcare organizationshould determine all areas that could be included in a complianceprogram by considering whatever federal, state, and/or localstatutes, regulations, and ordinances impose criminal or civil sanctionsor liability. Although this list is not intended to be exhaustive or complete,the laws that a healthcare organization should consider whencreating a corporate compliance program would include the following:• Antikickback statute and state or local counterparts• Antitrust laws• Civil monetary penalties laws• Emergency Medical Treatment and Active Labor Act (EMTALA)• Employment-related laws, such as the Americans with DisabilitiesAct (ADA), the Family and Medical Leave Act (FMLA), and theFair Labor Standards Act (FLSA)18OIG Supplemental Compliance Program Guidance for Hospitals, 70 Fed. Reg. 19,4859–4862 ( Jan. 31, 2005).19OIG, Publication, 8990–8993.20OIG, OIG Compliance Program for Individual and Small Group Physician Practices, 65Fed. Reg. 194, 59434–59435 (Oct. 5, 2000).