Doctor's Corner: A Primer on Compliance and Risk Management

Dr. Mike
Dec 22
2 min read

When physicians practice in the traditional models for their entire career, they are typically overwhelmed with the practice of medicine and have little bandwidth to allocate to non-clinical tasks. Then, when they leave traditional practices to venture into the direct care world, they are thrust into needing to know the details of topics to which they had only previously paid tangential attention: compliance and risk management. To help improve my own understanding for our clinic, I wrote up this document to organize the topics and eventually thought others may want to see it to get an overview of what is involved. Admittedly, I am not a lawyer and this information should only be seen as a rough guide. You will need to seek qualified legal counsel to ensure you have the information needed for your unique situation.

A big part of what drove me to look into this further were the ideas of discounts and patient inducements. On delving into the rules further, I learned that discounts can be a treacherous area for businesses as they may be unethical in medicine and may even venture into legal risks, particularly if your clinic participates in federal payment programs, such as Medicare. Similarly, inducements, or things a clinic may do to encourage a patient to join your clinic, may also expose you to risks of which you were unaware.

Another area of importance in direct care is quality improvement. Depending on how long you practiced in a traditional care model, you may have seen how quality metrics began as monitoring tools useful in local practice, ultimately morphing into issues potentially tracked by your medical society and tied to accreditation. The related issues were usually closely linked to patient care outcomes, so obtaining engagement by physicians was feasible. However, in some settings, metrics evolved into tools used by employers and/or payers to limit how much they paid and the link to patient care often became more tenuous, seemingly at times being arbitrarily punitive. Consequently, physicians may be reluctant to consider the idea of implementing quality metrics in their own direct care clinics. However, the use of valid quality metrics should be considered as a means of ensuring we are delivering the best care we can for our patients.

The following list shows the topics I briefly touch on in the primer:

1. Fraud and Abuse Laws

2. Anti-Kickback and Referral Restrictions

3. Professional Ethics and Licensing

4. Contractual and Compensation Risks

5. Privacy and Data Security

6. Scope of Practice & Supervision

7. Employment and Labor Law Risks

8. Tax and Nonprofit Considerations

9. Telehealth & Digital Health

10. Controlled Substances & DEA Compliance

11. Accreditation & Quality Reporting