Dallas Hospital Compliance and Audits
Hospitals in major cities like Dallas are at the center of the federal government’s fight against waste, fraud, and abuse in the healthcare system. Compliance needs to be a priority, and hospitals need to be prepared to defend themselves when they get audited.
Hospitals in the United States face extraordinary burdens. Not only must they ensure appropriate triage, diagnosis, and treatment of all patients that walk through their doors, but they must also employ comprehensive policies and procedures to ensure compliance with the federal laws and regulations that govern virtually all aspects of their operations.
From patient recordkeeping to Medicare billing, and from the characterization of workers to contractual relationships with physicians, hospitals must consider the compliance implications of virtually everything they do. If they don’t, they can expose themselves to substantial liability, and auditors will ensure that they are held fully accountable for their mistakes.
Hospital Compliance and Audit Defense Lawyers in Dallas, TX
Our firm represents hospitals in Dallas with regard to both compliance and audit defense. Our senior healthcare attorneys and hospital compliance consultants have centuries of combined experience, including prior experience as federal prosecutors and federal agents with the U.S. Department of Health and Human Services (DHHS), U.S. Drug Enforcement Administration (DEA), U.S. Department of Labor (DOL), U.S. Department of Justice (DOJ), and other agencies. Headquartered in Dallas, our practice is nationwide in scope, and we have helped hospitals and other providers in Texas and across the country avoid liability for costly compliance mistakes.
10 Core Components of an Effective Hospital Compliance Program
For hospitals in Dallas, there are numerous aspects of compliance that require detailed attention and careful implementation. Our lawyers and consultants provide comprehensive compliance representation, working directly with hospital executives, administrators, and physicians to develop custom-tailored policies and procedures that address the specific compliance risks our clients face on a day-to-day basis.
The following are 10 core components of an effective hospital compliance program. Within each of these areas, we offer customized services focused on protecting our clients against liability in the event of an audit or investigation:
1. Compliance Program Documentation
Hospital compliance programs must be documented in the form of thorough policies and procedures. These policies and procedures must address all pertinent compliance issues, and they must be written in such a way that they can be implemented effectively based on the unique structure and organization of the hospital. In other words, there is no such thing as a “standard” compliance program. A compliance program that is not specific to the facility that is attempting to implement it is not going to provide the protection that is necessary.
2. Employment and Independent Contractor Agreements
Employment-related issues can present particular challenges for hospitals. Properly classifying personnel as employees or independent contractors is of paramount importance, as misclassification is both a compliance concern and an issue that can lead to trouble with the Internal Revenue Service (IRS) and the Texas Comptroller. In addition to proper classification, hospitals must also ensure that their employment and independent contractor agreements contain adequate safeguards to mitigate their risk of liability.
3. Personnel Education and Training
Once the necessary compliance policies and procedures are in place, hospitals must then begin the process of implementation. Generally speaking, this starts with providing education and training to all pertinent personnel. Education and training programs should be customized to individual employees’ and contractors’ roles, and hospitals should ensure that completion of necessary education and training is appropriately documented.
4. Hospital Marketing Compliance
Marketing is an area of hospital compliance that often goes overlooked to disastrous effect. When engaging marketing groups and pursuing other marketing activities, hospitals must ensure that they are not putting themselves in a position to be accused of using program-reimbursed funds to pay for Medicare, Medicaid, Tricare, or DOL patient leads. Hospitals can market their services lawfully, but doing so requires a comprehensive understanding of the rules and regulations that apply.
5. Third-Party Contracting
In addition to agreements with employees, independent contractors, and marketing groups, hospitals must also address compliance-related considerations when contracting with vendors and other third parties. Contracts with third-party billing companies are one are of particular concern, but all agreements should be drafted with adequate protections based on the hospital’s specific risk profile.
6. Billing and Coding Compliance
Billing and coding are key compliance concerns for all hospitals and other healthcare providers. Unlawfully billing Medicare, Medicaid, Tricare, or the DOL can lead to recoupments, civil monetary penalties (CMP), program exclusion, and other penalties—and this is true regardless of whether your hospital has hired a third-party billing company. Not only must hospitals in Dallas implement compliant billing and coding practices, but they must also maintain documentary proof of their compliance efforts.
7. Internal Compliance Violation Reporting
When your hospital’s personnel make mistakes with compliance implications, you need to know about it as soon as possible. With this in mind, your hospital’s compliance program must include clear procedures for anonymously reporting witnessed or suspected compliance violations. There should be designated reporting channels with a specified chain of command, and hospital administrators should be prepared to respond swiftly once they receive information about a potential deficiency.
8. Compliance Violation Response
Hospitals’ compliance policies and procedures must include specific protocols for violation response. This includes both the internal response (i.e. addressing the violation and implementing appropriate employee discipline) and the external response (i.e. determining whether self-disclosure is necessary). If compliance violations are not addressed promptly, this failure can create just as many problems for the hospital, if not more, than the original violation itself.
9. Recordkeeping and Ongoing Compliance Documentation
When defending against a healthcare fraud audit, having adequate documentation on hand is absolutely essential. This includes not only documentation of your hospital’s policies and procedures, but also documentation of its ongoing compliance efforts. This means that hospitals need to be consistently generating records on an ongoing basis, and they need to adopt protocols for storing these records in an organized and easily-retrievable manner.
10. Audit Defense Preparedness
Finally, in addition to maintaining documentation of compliance hospitals must take other proactive measures to prepare for the possibility of defending against an audit as well. These measures should include establishing defense protocols, instructing personnel on what to do if they are contacted by auditors, and developing a step-by-step checklist for avoiding mistakes and mitigating liability.
12 Compliance Mistakes that Can Lead to Hospital Audits
Speaking of mistakes, when auditors examine a hospital’s compliance documentation, contracts, and billing records, there are several mistakes that they will be looking for. These mistakes are all likely to trigger additional inquiry; and, while there are defense strategies available, hospitals will often have a difficult time avoiding liability entirely when these mistakes have been made.
Over the course of decades of handling healthcare audits from both sides (as defense lawyers for hospitals and as former federal prosecutors and agents in the healthcare sector), we have identified 12 compliance mistakes that are particularly high-risk for hospitals and other providers. These mistakes are:
- Poor Documentation
- Mischaracterizing Employees (W-2s) and Independent Contractors (1099s)
- Utilizing Unlawful Marketing Contracts
- Failing to Establish Medical Necessity
- Disregarding the Patient
- Entering into Sham Contracts
- Failing to Secure Legal Protections in Billing and Coding Agreements
- Believing that Having HIPAA Policies Means compliance
- Underestimating Insurance Audits
- Telemedicine Violations
- Lack of Oversight and Contractual Protections
- No Demonstrated Efforts to Comply
For more information on each of these common mistakes, you can read: The Top 12 Mistakes When it Comes to Healthcare Compliance.
We Represent Dallas Hospitals in MAC, RAC, UPIC, Private Insurance, and Other Audits
Hospital compliance audits come in many different flavors. On the Medicare side, fee-for-service contractors working with the Centers for Medicare and Medicaid Services (CMS) – including Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Unified Program Integrity Contractors (UPICs) – aggressively pursue recoupments since they are compensated based on the amounts of alleged overpayments they recover. Tricare and DOL auditors are similarly aggressive, and private health insurance companies preserve extremely broad auditing rights in their hospital contracts.
When facing an audit, there are several facts that hospital executives and administrators need to know. First, the audit is not simply going to “resolve itself.” If you do nothing, the auditors will find reasons to demand recoupments, and appealing the outcome of an audit can be a lengthy, difficult, and expensive process. Second, by taking a proactive approach to fending off liability, hospitals can often save significant time and effort while also mitigating their risk of being audited again in the future. Third, even if mistakes have been made, there are ways that hospitals can avoid and mitigate their liability with the help of experienced healthcare fraud defense counsel.
Speak with a Dallas Hospital Compliance and Audit Defense Lawyer at Oberheiden P.C.
If your hospital’s compliance program is inadequate or out-of-date, if your hospital is being audited, or if you simply have questions about mitigating your hospital’s risk exposure, we encourage you to get in touch. To speak with a hospital compliance and audit defense lawyer at Oberheiden P.C. in confidence, call 888-680-1745 or request a free consultation online now.