It is a specific program first set out in the Code of Federal Regulations in 2003. Initially voluntary, healthcare compliance programs have since been made mandatory by subsequent laws such as the Affordable Care Act and guidance from the U.S. Department of Justice.At EMS Compliance, we believe compliance should be attainable for all EMS agencies, and not just the ones large enough to justify the expense of a full-time compliance officer. That is why we offer the Comprehensive Healthcare Compliance Solution for a low monthly fee covered by the reimbursement from a single ambulance transport.
The federal regulations state the “ambulance industry is comprised of entities of enormous variation: some ambulance companies are large, many are small; some are for-profit, many are not-for-profit; some are affiliated with hospitals, many are independent; and some are operated by municipalities or counties, while others are commercially owned.” Despite this diversity, there are seven elements the regulations require of all EMS providers. In summary, they are:
The implementation of written compliance policies, procedures and standards of conduct;
Designation of a compliance official and/or compliance committee;
Compliance training and education for your employees;
Methods for reporting compliance issues such as an anonymous reporting hotline;
Internal and external monitoring/auditing of compliance issues such as proper Medicare billing;
Established enforcement standards for unethical or illegal conduct;
Procedures to promptly detect and fully investigate non-compliant behavior.
Compliance is primarily enforced by the Office of Inspector (OIG) of the U.S. Department of Health and Human Services. OIG agents operate much like FBI agents (they often coordinate activities) and are located in offices throughout the country.
In its annual work plan, the OIG states “Medicare pays for different levels of ambulance service, including basic life support, advanced life support, and specialty care transport (42 CFR §410.40(b)). Prior OIG work found that Medicare made inappropriate payments for advanced life support emergency transports. We will determine whether Medicare payments for ambulance services were made in accordance with Medicare requirements.” This initiative began in 2018 and is ongoing.
The OIG and Medicare utilize many methods in ensuring compliance. They range from monitoring your Medicare claims behind the scenes to targeted audits and even investigations into your organization that involve secretly interviewing past and present employees.
The greatest risk is massive fines or individuals within your organization being held personally liable for violations of federal fraud and abuse laws. In order to be effective, you need a compliance program in place before any enforcement action by the government. In its guidance to U.S. Attorney offices across the country, the DOJ says prosecutors must take into account “the adequacy and effectiveness of the organization’s compliance program at the time of the offense.”
YES! In fact, one of the seven elements of a compliance program is monitoring and auditing your billing company. You put yourself at greater risk if you simply leave everything to your billing company. Also, the government expects compliance programs to cover much more than just Medicare billing. Some of the greatest risks and largest fines have nothing to do with submitting EMS claims; such as Anti-kickback statutes and Medicare and Medicaid cost reporting.
