Compliance, Auditing, and Program Integrity
The compliance framework
RHC compliance rests on the same seven elements as any Medicare compliance program: written policies, a compliance officer and committee, training, communication lines, internal monitoring, enforcement, and corrective action. Candidates must understand how these elements apply to the RHC's specific risks: encounter-rate billing, midlevel supervision documentation, and the location/shortage certification. The RHC must also comply with the Physician Self-Referral (Stark) Law and the Anti-Kickback Statute, which affect arrangements with referring physicians and ancillary service providers.
Auditing
Internal audits should sample encounters and verify: (1) a face-to-face visit occurred, (2) the practitioner was qualified and on-site as required, (3) the service was within scope, and (4) the documentation supports the level billed. External audits by Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs) focus on the same elements, plus the accuracy of the cost report. Know the difference between a MAC audit (claims and cost report) and a RAC audit (improper payments).
Traps
Common exam traps: confusing the compliance officer's role with the medical director's; assuming a compliance program is optional (it is strongly encouraged and often required by payer contracts); and overlooking the self-disclosure obligation when an overpayment is identified. Another trap is the 60-day rule for returning identified overpayments.
Worked example
An audit finds that an NP saw patients on a day when the supervising physician was unavailable and no covering physician arrangement existed. The RHC must refund the affected encounters, document corrective action, and consider self-disclosure if the pattern is systemic.
Rule of thumb
Every billed encounter must survive four questions: Did it happen? Was the practitioner qualified? Was it in scope? Does the documentation support it?