Turning Lemons Into Lemonade: Medicaid’s Compliance Plan Requirement


I read your email a few weeks ago about Medicaid’s compliance plan requirement and after considering that “ordered” services are included in the $500,000 precipice as well as straight Medicaid payments and all Medicaid HMO payments, I realized that my practice does qualify. I can’t believe there this is another thing I need to put money into that the government is requiring, when all the government does is take money away from my practice’s reimbursement. Are there any benefits of purchasing a compliance plan since I have to get one?

Dr. P.O.’ed

Doc, I understand your frustration. You are not the first, nor will you be the last I hear complaining about the government in general, or Medicaid’s compliance plan requirement specifically. There are certainly benefits to adopting and integrating a good compliance plan with your practice in addition to avoiding a fine, etc from Medicaid. By doing so not only will you be limiting your potential exposure under audit or investigation, but you will also most likely capture more of your reimbursement. Reason being, when adopting a compliance plan, you are adopting set policies and procedures for your practice’s billing and staff responsible for billing. You are establishing oversight procedures, designating red flags and designating a chain of command for addressing outstanding matters.

Without established billing policies and procedures your practice may as well be set up as a tag sale with no one at the register, which is why New York State is electing to require every practice within the precipice have one – to cut down billing errors. I can tell you that your frustration with paying money for a compliance plan you have no intention to integrate into your practice is absolutely legitimate, as any such document would go to waste. Since you do qualify under Medicaid’s requirement, my suggestion is you use this requirement as a positive opportunity to evaluate your practice’s billing procedures and adopt new policies to better your practice. Hence, the lemons to lemonade title…