Corrective Action Plan Lawyer
Our Lawyers Help Healthcare Providers Develop Corrective Action Plans to Meet Medicare, Medicaid, Tricare, and Private Health Insurance Requirements
Corrective Action Plan Team Lead
Healthcare providers that bill Medicare, Medicaid, Tricare, and private health insurance companies are subject to strict billing rules and regulations. When providers violate these rules and regulations, they can face recoupments and other penalties. They can also face a requirement to implement a Corrective Action Plan.
If a government or private payor has indicated that your business or practice needs to implement a Corrective Action Plan, we can help. Our lawyers are highly experienced in advising healthcare providers and other entities regarding billing compliance. We routinely represent providers and other entities during billing compliance audits and investigations, and we work closely with our clients to help them avoid unnecessary penalties and unwanted scrutiny. If you are in need of a Corrective Action Plan lawyer, we can use our experience and insights to help preserve your business’s or practice’s billing eligibility.
What Is a Corrective Action Plan in Healthcare?
A Corrective Action Plan in healthcare is a documented set of steps that a provider will take to remedy billing compliance deficiencies and maintain compliance in the future. Medicare, Medicaid, Tricare, and private health insurance companies can require providers to implement Corrective Action Plans when they uncover significant or systemic violations during billing compliance audits and investigations.
Generally, when payors indicate that participating providers need to implement Corrective Action Plans, failure to do so can lead to loss of eligibility (in the case of Medicare, Medicaid, or Tricare) or contract termination (in the case of a private health insurance company). As a result, providers need to take Corrective Action Plan requirements seriously, and they need to ensure that their Corrective Action Plans are adequate to meet their compliance obligations.
What Are the Key Elements of a Corrective Action Plan?
A Corrective Action Plan has several key elements. Healthcare providers must include all elements in their plans, and they must thoroughly document their efforts so that they can demonstrate their good-faith compliance efforts to the relevant payor.
Payors will generally accept well-documented Corrective Action Plans that follow the “IERAIF” methodology. When following this methodology, the key elements of a Corrective Action Plan in healthcare include:
- Root Cause Analysis
- Action Plan
The first element of an effective Corrective Action Plan in healthcare is “Identification.” This involves identifying the specific issues that require correction. In many cases, identifying the relevant issues will be relatively straightforward, as they will have already been identified during the audit or investigation process.
However, understanding exactly why an audit or investigation led to an unfavorable outcome can be difficult in some cases. Simply put, auditors’ and investigators’ findings aren’t always as clear as they should be. Before moving forward with efforts to update their billing compliance programs and remedy compliance deficiencies, healthcare providers first need to ensure that they are targeting the relevant issues.
The second element is “Evaluation.” After identifying the issue (or issues) that resulted in a provider’s billing violations, the provider must evaluate these issues to determine their magnitude and overall effect. The more widespread an issue proves to be, the more effort the provider will need to put into correcting the issue. Likewise, if certain issues result in substantial overbillings, then providers will need to show that they are giving these issues the extra attention they demand. Ultimately, the goal here is to demonstrate to the relevant payor that your business or practice is taking the need for a Corrective Action Plan seriously, and that you have an appreciation for the need for corrective action.
Root Cause Analysis
After identifying and evaluating the issues at hand, the next step is to conduct a root cause analysis. In many respects, this is the most important element of a Corrective Action Plan.
A root cause analysis focuses on understanding why a particular issue exists. When a healthcare billing audit or investigation uncovers multiple issues, the provider must conduct a root cause analysis with respect to each individual issue—as their respective root causes could all be different. Is the provider’s billing compliance program deficient or outdated? Do the provider’s billing personnel lack requisite knowledge? Are the provider’s billing personnel simply being careless, or do they lack an appreciation for the importance of billing compliance? These are just a small sampling of potential root causes that could lead to Medicare, Medicaid, Tricare, and private health insurance billing violations.
Once a healthcare provider knows why it has submitted inaccurate billing statements, it can then shift its focus to taking corrective action. The steps that are necessary to correct billing failures will depend on the scope and nature of the issue (or issues) at hand. Some examples of actions that may be necessary include:
- Updating or Revising the Business’s or Practice’s Compliance Program – If a provider’s billing compliance program has become outdated due to changes in the applicable billing rules or regulations, then updates may be long overdue. Alternatively, revisions may be necessary to address fundamental deficiencies in the provider’s compliance program.
- Overhauling the Business’s or Practice’s Compliance Program – In some cases, updates are so long overdo or issues are so widespread that a complete overhaul is needed. If a provider has neglected its billing compliance obligation, then starting over from scratch may be the most prudent and most efficient approach.
- Providing Additional Training to Medical or Billing Personnel – Sometimes, the issues don’t lie with a provider’s compliance program, but rather with its efforts to implement the program on a business-wide scale. In these scenarios, providing additional training may be sufficient to prevent billing violations going forward.
- Adopting More Robust Billing Verification Procedures – Healthcare providers should have procedures in place to verify the accuracy of their Medicare, Medicaid, Tricare, and private insurance billings. Lack of internal review and auditing procedures is a common reason for unfavorable audit and investigation outcomes. Ineffective review and auditing procedures are common issues as well.
- Instituting Enforcement or Incentive Programs for Compliance – Providers can also improve their compliance rates by instituting enforcement and incentive programs. Personnel who are individually responsible for billing violations should be held accountable, and those who show a commitment to compliance should receive appropriate recognition.
With an action plan in place, the next phase is “Implementation.” This is fairly self-explanatory, although effectively implementing substantial updates to a business’s or practice’s billing compliance program can be a substantial undertaking. However, without effective implementation, an action plan will not serve its intended purpose—in fact, failures at the implementation phase can signal to payors that providers are not adequately committed to compliance.
After implementing their action plans, healthcare providers must follow up to ensure that their renewed compliance efforts are effective. These follow-up efforts can align with providers’ efforts to ensure compliance on an ongoing basis as part of their regular processes and procedures—although in the immediate aftermath of an unfavorable audit or investigation, more robust follow-up measures may be necessary. Ideally, providers’ follow-up efforts will confirm that their Corrective Action Plans are working; but, if they aren’t, these follow-up efforts will serve to ensure that providers can take further corrective action before facing additional outside scrutiny.
FAQs: Implementing a Healthcare Corrective Action Plan
Why Do Medicare, Medicaid, Tricare, and Private Health Insurance Companies Require Corrective Action Plans?
Medicare, Medicaid, Tricare, and private health insurance companies require Corrective Action Plans when they uncover significant or systemic violations during billing compliance audits. If your business or practice is being asked to adopt a Corrective Action Plan, you will want to discuss your situation with an experienced lawyer promptly.
What if I Disagree that My Healthcare Practice or Business Needs a Corrective Action Plan?
If you disagree that your healthcare practice or business needs a Corrective Action Plan, you will need to successfully challenge the outcome of your billing audit or investigation. Doing so will require the advice and representation of experienced outside counsel.
Do Healthcare Providers Need to Engage a Corrective Action Plan Lawyer?
Given the nuances involved with developing an effective Corrective Action Plan and the consequences of failing to adequately address billing compliance failures, we strongly recommend that providers engage a Corrective Action Plan lawyer to assist them.
What Are the Risks of Failing to Implement an Effective Corrective Action Plan?
Failing to implement an effective Corrective Action Plan presents several risks. Providers can face denial of pending claims, prepayment review, loss of eligibility, and other penalties; and, in many cases, failure to remedy knowing billing compliance failures can lead to additional scrutiny from auditors or federal authorities.
Speak with a Corrective Action Plan Lawyer at Oberheiden P.C.
If your healthcare business or practice needs to implement a Corrective Action Plan, we invite you to contact us for more information. We work with healthcare providers nationwide. To speak with a Corrective Action Plan Lawyer at Oberheiden P.C. in confidence, please call 888-680-1745 or tell us how we can reach you online today.