• Our health care system is complex. Ensuring compliance with federal laws and regulations is necessary to avoid fraud, abuse, and waste and to eliminate improper payments. Practices that embrace compliance principles in their practice culture can help to prevent problems from occurring in the future, speed and optimize payment of claims, reduce billing mistakes, mitigate the risk of an audit, and avoid conflicts with antikickback and self-referral laws.

    Below are resources and tools to assist physical therapists with compliance in their practices.

    Guidance from the Office of Inspector General

    The Office of Inspector General (OIG), US Department of Health has provided several training videos and podcasts designed to help. They can be found on the OIG Website.

    Guidance from APTA

    APTA offers information and resources to help physical therapists remain compliant available at www.apta.org/Compliance/.

    APTA, AOTA, ASHA, and NASL have collaborated to issue guidance for compliance reporting (.pdf).

    For questions about compliance or any of APTA's resources contact advocacy@apta.org.

    Review FAQ: Fraud & Abuse

    Compliance Program Guidance

    To protect federal programs from fraud, abuse, and waste, the Affordable Care Act mandates compliance programs to prevent violations of Medicare and Medicaid regulations. While the effective date for implementation has not yet been set, it is highly recommended that providers of physical therapy establish a compliance program to cultivate a culture of compliance in their setting.

    The OIG has identified 7 core elements that provide a solid basis upon which you can develop a compliance program. These elements are likely to serve as the foundation of the new compliance program requirement:

    1. Develop and distribute written policies, procedures, and standards to prevent and detect inappropriate conduct
    2. Designate a compliance officer or contact person
    3. Conduct effective compliance education and training programs
    4. Develop open lines of communication, including a process to receive complaints (a "hotline"); adopting procedures to protect the anonymity of those reporting compliance concerns/issues; and implementing a nonretaliation policy for those reporting compliance issues and violations
    5. Perform ongoing internal evaluation through monitoring and auditing processes
    6. Enforce compliance standards through well-publicized disciplinary guidelines
    7. Respond appropriately to detected and reported compliance issues/violations

    The OIG has developed a series of voluntary compliance program guidance documents directed at various segments of the health care industry, such as hospitals, nursing homes, third-party billers, individual and small group physician practices, and durable medical equipment suppliers, to encourage the development and use of internal controls to monitor compliance with statutes, regulations, and program requirements. The documents provide principles to follow when developing a compliance program that best suits an organization's needs.

    Related Laws

    ADA

    The American with Disabilities Act (ADA) prohibits discrimination on the basis of disability in employment, state and local government, public accommodations, commercial facilities, transportation, and telecommunications. It also applies to the United States Congress. To be protected by the ADA, one must have a disability or have a relationship or association with an individual with a disability.

    HIPAA

    The Health Insurance Portability and Accountability Act (HIPAA) imposes numerous requirements on patient privacy and security issues. APTA offers informational resources and links for providers to learn about compliance with HIPAA regulations. Go There.

    Version 5010 Electronic Administrative Transactions

    If you electronically submit administrative transactions, such as checking a patient's eligibility, filing a claim, or receiving a remittance advice, either directly to a health insurance payer or through a clearinghouse, the version of the transactions currently in use must be updated to Version 5010 Electronic Administrative Transactions (5010). On January 16, 2009, the Department of Health and Human Services (HHS) announced that updated versions of the HIPAA transactions will be required for use by physical therapists and others on January 1, 2012. The Centers for Medicare and Medicaid Services (CMS), is the agency within HHS charged with overseeing compliance with the standards. Review APTA Version 5010 resources.

  • Last Updated: 9/22/2016
    Contact: advocacy@apta.org