Compliance Action Plan

Responsible Target Complete

Issue No. Action Items Notes
Parties Date Date

Compliance General
Compliance Training 1 General compliance training for all
Department employees and Training session to be done after hours non-exempt
Management on recognizing and employees will be paid to attend. CEO to open session
reporting potential compliance CO to conduct training.
issues.
2 Educate Department Managers
See 1 above.
regarding compliance program.
3 Add compliance column to
Every other month.
Newsletter.
4 Publish and educate all employees
on Code of Conduct.

5 Job-specific compliance training for

all Department employees and See 1 above.
Management.
6 Educate staff, physicians and
management on proper use of See 1 above.
ABNs.
7 Arrange for appropriate physician
training on E/M coding by an On hold until audits are completed.
external resource.
8 Train physicians on compliance. On hold until audits are completed.
9 Follow up on all training to make
On hold until audits are completed.
sure it takes root.
10 Communicate to Department
employees that the issue is being
See 1 above.
addressed, and validate their
concerns.
11 Educate employees on how to
appropriately report compliance See 1 above.
concerns.
Compliance Program Review 12 Create customized Compliance
Present recommendations to Compliance Committee.
Programs for each entity.
Coding references 13 Retrieve all existing coding
references at the Department, check
Request information from Department managers.
them for accuracy, and revise them
as necessary.

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 Compliance Action Plan
Responsible Target Complete
Issue No. Action Items Notes
Parties Date Date
14 Develop inventory of required
policies and procedures.
15 Write policies and procedures noted
in 14 above.

Compliance Project
Government audit 1 Continue to communicate with
investigators representative and
work toward resolution.
2 Monitor mail for communication from
FI on any further action on this
issue.
Audit charges for ____ visits 3 Gather data to validate whether
Complete.
there is an issue.
4 Create separate Action Plan and
take all necessary remedial actions.

_____ coding and billing 5 Gather data to determine whether

Next priority after completion of E/M Project.
there is an issue.
6 Create separate Action Plan and
take all necessary remedial actions Next priority after completion of E/M Project.
if there is an issue.
Department's ______ charges 7 Gather a random sample of charges
and validate whether there is an Next priority after completion of E/M Project.
issue.
8 Create separate Action Plan and
take all necessary remedial actions Next priority after completion of E/M Project.
if there is an issue.
Credit Balances 9 Review credit balance reports for all
payors. Assuming there is no issue, Next priority after completion of E/M Project.
document in Memo to file.
HIPAA Assessment 10 Conduct a "walk through" of
Department and perform a HIPAA
assessment. Make any necessary
changes and communicate to staff.

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 Compliance Action Plan
Responsible Target Complete
Issue No. Action Items Notes
Parties Date Date
OSHA Review 11 Conduct a "walk through" of
Department with custodial and
maintenance staff. Make any
necessary changes and
communicate to staff.
Review of the ______ billings 12 Evaluate need for discovery sample Based on the review of records done related to ____,
audit. no further action required.
13 Document recommendations.

Management

Compliance program structure 1 Discuss program structure and

management and enact any
appropriate changes.
Billing staff personnel issues 2 Evaluate and educate as
appropriate.
Work environment. 3 Evaluate and develop action plan to
resolve any identified issues.
Department staff training 4 Assess substantive knowledge of
staff and obtain appropriate
training/education for them.
Improve communication and 5 Work with Department to set up face-
collaboration to-face communication between
staff, with a set agenda to go over
recurring issues.
_____ responsibilities 6 Create a new job description for Hold for completion of overall Compliance Program
position. plan.
Delineation of roles between 7 Communicate with management and
staff revise management structure and
accountabilities.
Senior Management 8 Clearly define job responsibilities.

9 Consider revising the management

structure to ensure better
communication, collaboration, and
accountability.

Operations

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 Compliance Action Plan
Responsible Target Complete
Issue No. Action Items Notes
Parties Date Date
Commercial payor issues 1 Obtain copies of all payor audits.
Contract Review 2 Inventory of related contracts.
3 Work to get appropriate contracts in
place.
Audit follow-up 4 Communicate with Department
See 1 above under Compliance General; Compliance
about proper approach and
Training.
response to reports and audits.
Monthly Error Reporting 5 Establish procedures for the
documented accountability and
resolution of reported errors.
Billing Policies and Procedures 6 Develop inventory of appropriate
policies and procedures.
7 Write policies and procedures, and
communicate them to the
appropriate personnel.
8 Audit consultant report for
completion.
Forms approval process 9 Review policies and procedures on
new forms and refine as necessary.

Physician coding practices 10 Develop uniform practices, obtain

physician buy-in, and train
physicians and Department staff on
the new practices.

Human Resources
Staff Issues 1 Follow-up on issues raised by staff
to Human Resources.
Exit Interview Procedures 1 Communicate with Human
Resources personnel and develop
procedure for engaging in more exit
interviews and for capturing potential
compliance issues in the process.

1a Revised Exit Interview worksheet.

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 Compliance Action Plan
Responsible Target Complete
Issue No. Action Items Notes
Parties Date Date
Physician awareness 1 Communicate with physicians about
appropriate next steps and seek to
obtain their buy- in.

E/M Compliance Project

Physician audits 1 Completion of statistically valid
audits of physician records.
2 Project target date for completion of
physician audits.
3 Review of initial audit results
Response and repayment 1 Conduct further documentation,
coding, and billing audits and take
all necessary actions, including
repayment, to remedy all instances Build into the Compliance Program.
of non-compliance and to prevent
future compliance lapses.

Letter to Carrier 1 Notify Carrier of compliance issue

and status of work being done.

Physician Communication
1 Project Update.
Monitoring of Action Plan 1 Meetings a necessary to monitor
progress of implentation of action
plan.

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