The Corporate Compliance Plan, which is traditionally operated and well known in Medicare and Medicaid areas of practice, can have benefits in the area of no-fault billings and protections against no-fault insurance company lawsuits. The Plan can be set up to monitor fraud and abuse, patient privacy issues, and billing collection issues. However, since the no-fault carriers are not of themselves government entities, the protections of a Corporate Compliance Plan are not as clear at first. There is also less of an incentive to attempt to enforce criminal penalties as opposed to pursue civil lawsuits for fraud or for RICO actions against providers in the no-fault field.
The Compliance Plan in Medicare and Medicaid areas serves best to demonstrate a provider’s attempt at compliance with regulations and thus negate any potential criminal liability or civil penalties associated with an intentional act.
In the context of no-fault, however, since the carriers are ultimately looking for money back, the compliance plan can provide a benefit to the provider, though not as clear-cut or apparent as in the Medicare and Medicaid arena. A provider in no-fault that has a compliance plan could very well demonstrate to a carrier in order to increase their collections, that they indeed have such a plan which operates on the same level of scrutiny as a Medicare or Medicaid plan. The existence of the plan could act to remove them from EUO protocols and scrutiny by the insurance carrier. Additionally, due to the large amount of paper claims a typical no-fault practice submits, self-auditing by a third party, including audit reports, could very easily pick up and clear up any mistakes or shortfalls in billing, which could lead to a lower collection rate overall.
In the event a carrier files a lawsuit against the provider which would allege fraud or some form of intentional wrongdoing, a corporate compliance plan that is properly structured with periodic self review and self audits, and is properly maintained, can be used in connection with any defense. It will lend strength to the provider’s arguments and defenses with respect to certain claims in court or in their negotiations for a settlement directly with the insurance carrier. This is because the provider took steps to establish and follow policies and protocols to make sure they are in compliance with applicable laws and regulations.
One of the common factors between a Medicare and Medicaid allegation of fraud and a no-fault insurance carrier’s claim for civil fraud and civil action is that in both cases, intent is required. Even though it is not as clear-cut, the benefit of a compliance plan to help negate the intent in the civil actions is still fairly obvious. Such a plan can help defend the individual owner of the practice and remove them from the personal liability that any fraud or intent-based claim could raise.
It is important to remember that the benefits of such a compliance plan, while it may seem like excess policies and procedures to implement, can provide:
- A practical benefit to billing and identifying deficiencies in your own practice discovered through self-audits conducted by a third party.
- A formal intent to no-fault carriers that it is the provider’s desire to comply with the law and to work with the carriers to resolve any issues.
- Additional protection and ammunition as well as a defense for the provider in the event of any litigation, by helping to remove the most damaging areas of a claim and potential personal liability for a provider caught up in such a lawsuit. In addition, it makes it more difficult for an insurance carrier to prove such claims.
Do you have a Corporate Compliance Plan? Could your practice benefit from putting one in place?