Detected Offenses [Healthcare Compliance Tips]

Respond appropriately to detected offenses and develop corrective action plans within your practice.

As discussed in our previous tip, we shared the 7 Elements of an Effective Compliance Program.  Our focus has shifted to the fifth element, which is responding appropriately to detected offenses and developing corrective action plans are critical.

When a compliance incident occurs, the first step is to ensure the compliance officer or designated employee(s) review the allegation to determine whether it is a violation and/or if corrective action can be pursued.

Always proceed with caution and investigate thoroughly before making any final decisions because it may be a misunderstanding due to unclear rules or guidelines.

The OIG recommends that when internal issues are involved, individuals should be retrained, disciplined, or terminated depending on the violation.

However, practices should also look out for external warnings, such as:

• Number/or types of claim rejections
• Correspondence from insurance companies
• Illogical or unusual changes in coding patterns (i.e., CPT, HCPCS, ICD-10, etc.)
• High volumes of unusual charge or payment adjustments.

A good compliance team will create a plan to detect these types of offenses, in which violations should be documented appropriately.

 **The opinions and observations from the group/author are not a promise to exempt your practice from fines and penalties.  Research, modify, and tailor the advice to fit your specialty.