Medicare compliance requirements are still pending

Medicare providers awaiting guidance from HHS on how to meet compliance program requirements under the Affordable Care Act.

Recently, some members have raised concerns about Medicare compliance requirements under the Affordable Care Act (ACA). While the ACA requires Medicare and Medicaid providers to have a compliance and ethics program in place, Congress left the timing and implementation of these requirements up to the Department of Health and Human Services (HHS).  

To date HHS has issued detailed guidance on compliance requirements for nursing facilities, Medicare Advantage plans and Medicare prescription drug plans. HHS has not indicated when it expects to release guidance on the compliance requirements under the ACA for individual and small group practices.

Members are encouraged to begin or continue compliance efforts in anticipation of ACA compliance guidance being released. HHS has encouraged health care providers since the late 1990s to implement voluntary measures to guard against fraud, waste and abuse of government health care programs. The stated goal of the HHS Office of the Inspector General (OIG) has been to engage the private health care community in preventing the submission of erroneous claims and in combating fraudulent conduct related to government health care programs.

In 2000, the HHS OIG released Compliance Program Guidance for Individual and Small Group Physician Practices (PDF, 346KB), which members can view as a reference. HHS OIG also offers videos on compliance for health care providers. The October 2000 voluntary compliance program guidance establishes seven core elements that should be included in a compliance program for individual and small group practices: 

  1. Conducting internal monitoring and auditing.
  2. Implementing compliance and practice standards.
  3. Designating a compliance officer or contact.
  4. Conducting appropriate training and education.
  5. Responding appropriately to detected offenses and developing corrective action.
  6. Developing open lines of communication.
  7. Enforcing disciplinary standards through well-publicized guidelines.

It is important to note that the anticipated ACA compliance requirements are separate from Health Insurance Portability and Accountability Act (HIPAA) compliance requirements.

We will keep members apprised through the PracticeUpdate newsletter when further information is released regarding Medicare compliance programs.