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Last Modified: 6/24/2022 Location: FL, PR, USVI Business: Part A, Part B

Develop and implement a compliance program

A well-designed compliance program will not only help you submit accurate Medicare claims and prevent fraud but may also result in a better-run practice. A compliance program can prevent, identify, and correct inappropriate activities of employees and/or billing companies. It could also reduce your exposure to liabilities and penalties.

Where can I look for guidance?

The Office of the Inspector General (OIG) website, at provides information on implementing a compliance program, and includes examples of simple compliance program models.
Although the compliance guidance is not mandatory, any physician would be well advised to consider the OIG’s suggestions.

Fundamental elements of an effective compliance program

Implementing written policies, procedures, and standards of conduct
Designating a compliance officer and compliance committee
Conducting effective training and education
Developing effective lines of communication
Conducting internal monitoring and auditing
Enforcing standards through well-publicized disciplinary guidelines
Responding promptly to detected offenses and undertaking corrective action

Practical tips

Make compliance plans a priority now
Know your fraud and abuse risk areas
Manage your financial relationships
Just because your competitor is doing something doesn’t mean you can or should
When in doubt, ask for help

Ideas for operating an effective compliance program

Develop benchmarks and goals, and set up a system to measure how well you are meeting those goals.
Regularly review and update training programs, and train yourself and your compliance staff. Attend conferences and webinars, subscribe to publications, and network with peers to stay up-to-date and get ideas.
Have open lines of communication between you and your employees and use newsletters or internal websites to maintain visibility with employees.
Perform proactive reviews in coding, contracts, and quality of care. Create an audit plan and re-evaluate it regularly.
Act promptly. Take appropriate corrective action and create a system or process to track resolution of complaints.

Helpful hints to follow for a more efficient practice: Make your billing service company work for you

Providers are ultimately responsible for claims and payments, even if they use a billing service. First Coast recommends you conduct regular reviews of the charges that third-party vendors are submitting to Medicare on your behalf.
Helpful questions to ask include:
How many claims have been paid by Medicare?
Do you have any claims pending? How long have they been pending? What is the dollar amount pending?
How many of your claims denied/rejected? Why did they deny/reject?
Are errors being made? Where are these errors originating from (staff, claim billing system/clearing house)?
Consider having your billing company trend the data and report the outcomes directly to you. If you are not using a billing service, have an internal process in place in which your staff monitors and reports this information to you on a regular basis.

Pay attention to medical documentation

Remember to document patient encounters thoroughly and maintain medical records in a format that facilitates efficient retrieval.
If you receive a request for medical records, respond promptly. A late response could result in claim denial.
Be aware of the timeframe for filing an appeal and be clear on what you are appealing.
Additional information on the appeals process is available in the FAQ section of this site.
Checklists are available in the Medical Documentation section of this site to help providers when responding to documentation requests.

Compare the health of your administrative processes to others

Providers and suppliers may request a comparative billing report (CBR) to compare their business practices to others in the same specialty payment area, or locality.  A provider-specific CBR can be helpful when conducting self-audits, and the results of the comparison may suggest an opportunity for changes or educational intervention. Ordering instructions are available for both Part A and Part B providers.

Check the Medicare eligibility of your patients

Before filing a claim with First Coast, verify if your patient has traditional Medicare or a Medicare Advantage (formerly Medicare + Choice) plan. Always ask to see the beneficiary's Medicare card prior to providing services and verify Medicare eligibility via the SPOT or the toll-free interactive voice response unit (IVR) at 877-602-8816 (Part A) or 877-847-4992 (Part B). In addition, determine if Medicare is the primary or secondary payer. Visit our Medicare secondary Payer (MSP) page for more information.
Also, take advantage of the SPOT; again, not only for claim status, but for eligibility and benefits, payment information, and comparative billing data in a secure online environment.

Stay current on changes to the Medicare program

The best way to stay current on changes to billing guidelines and coverage policies is for you and your staff to sign-up for our electronic First Coast eNews which informs you of the latest Medicare news, information, and resources available on our website.
To subscribe select “Join eNews” in the top section of this site to sign up today
Other important tools are available at the CMS website external link

Keep your Medicare provider enrollment data current

Make sure to keep your Medicare file updated with First Coast.
You are required to notify Medicare within 30 days of making a change to your practice location, pay-to address, etc.
Ask Medicare to delete old provider numbers that you no longer use.
Finally, when receiving payment via electronic funds transfer (EFT), notify Medicare enrollment prior to changing or closing the bank account to prevent payment disruption.

Compliance resources

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.