Compliance
Compliance protects the organization, patients, and public payers from fraud, abuse, and error. RHITs must know the major fraud-and-abuse laws, the elements of a compliance program, and the audit contractors that review claims.
Fraud and abuse laws
The False Claims Act prohibits knowingly submitting, or causing the submission of, false or fraudulent claims to a federal program; it allows whistleblower (qui tam) suits and treble damages, and upcoding an unsupported DRG is a classic violation. The Anti-Kickback Statute bars offering or receiving anything of value to induce referrals of federally reimbursed services, and the Stark Law prohibits physician self-referral to entities with which they have a financial relationship. HIM staff who spot documentation-versus-coding mismatches are often the first line of defense.
Compliance programs and audit contractors
The OIG describes seven elements of an effective compliance program: written policies and standards; a designated compliance officer and committee; effective training and education; open lines of communication; internal auditing and monitoring; enforcement through disciplinary standards; and prompt response and corrective action. The OIG Work Plan signals audit priorities each year. Recovery Audit Contractors (RACs) review paid Medicare claims to recover improper payments (mostly overpayments), and HIM supports these audits by producing records and managing appeals.