Your supervisor has just questioned you regarding the policies and procedures of the healthcare compliance program. You understand that even if you have heard about this subject, your knowledge is insufficient to provide a meaningful response. Furthermore, please realize that “privacy rules” and “HIPAA Security Standards” are not the same thing, yet they are linked!
What does a healthcare organization’s compliance program entail? You make the decision to start a thorough investigation into the guidelines and practices of healthcare compliance programs.
Rules that apply to the policies and procedures of the Healthcare Compliance Program
“What regulations apply to healthcare compliance program policies and procedures?” is the first question that pops into my head. The quick response is: not a lot! Actually, skilled nursing facilities are the only healthcare institutions mandated by law to maintain a compliance program. The Office of Inspector General (OIG) provides assistance on compliance strategies to other healthcare institutions, such as hospitals, home health agencies, laboratories, physician groups, third-party billing firms, and ambulance companies.
Laws and regulations are not the same as regulatory agency guidance. It is optional to implement a compliance program, even one that follows the OIG guidelines. However, in the modern era, failing to follow the OIG guidelines for your particular kind of healthcare business might be regarded as managerial malpractice. Ultimately, the goal is to establish a successful compliance program within a healthcare institution.
And additional legally mandated compliance initiatives might be in the works. The Health and Human Services Department (HHS) was mandated by the Affordable Care Act (ACA) of 2010 to publish regulations on healthcare compliance initiatives. The rules would spell out what compliance plans must be in place before any healthcare provider can bill Medicare for goods or services. The compliance guidelines established for skilled nursing institutions are also derived from the ACA.
Policies and Procedures for Compliance and OIG Guidance
What guidelines does the OIG have regarding the rules and procedures of healthcare compliance programs? The OIG has published guidelines that all refers to the same seven components of a successful compliance program in the healthcare industry, regardless of the type of business. Among those components are written policies and procedures as well as written standards of behavior.
Program Content for Healthcare Compliance
A policy outlining the organization’s compliance program is one of the cornerstones of a compliance plan in the healthcare industry. Typically, this policy will include the essential components of the program, like:
the organization’s dedication to abiding by all applicable state and federal rules and regulations. It should also outline the company’s dedication to preventing misuse and fraud in relation to billing and claims procedures.
The duties and obligations of the people in charge of monitoring the compliance plan. The governing body, the compliance officer, and the compliance committee are typically included in this.
the healthcare organization’s risk regions. Making accurate claim submissions is a significant risk area for the majority of healthcare companies who take part in Medicare and/or Medicaid. However, there are other people. (1) The Stark Law and the Anti-kickback Statute provide a risk to any Designated Healthcare Service that has a financial connection to a doctor who also refers patients to the service. Hospitals are exposed to danger when it comes to Medicare Cost Reports. (3) All entities that submit claims run the risk of having credit balances returned or overpayments made. Employing employees who have previously been denied access to government healthcare programs puts all firms filing claims at risk.
regular instruction. All employees must get training on the organization’s compliance standards. (1) Executives and members of the governing body should get training that specifically addresses their responsibilities for monitoring the compliance plan. (2) Training suitable for their roles as clinicians, other professionals, and support personnel should be provided to managers, staff members, and clinical providers.
efficient channels of communication. The existence of whistleblowers is a recurring characteristic in cases where an organization violated claims-related laws and regulations. These people have knowledge of, or suspicions about, errors being made in the filing or preparation of applications for government programs. However, they had no practical means of expressing these worries. Concerns were occasionally expressed but disregarded.
Additional Content of Policies and Procedures for the Healthcare Compliance Program
utilizing widely published Disciplinary Guidelines to enforce policies. If professionals or other staff members make mistakes in the billing or coding of claims or in the reporting of medical records, a lot more is at risk for healthcare companies. Employees may feel shielded from the fallout from errors that require reimbursement of cash that were already received. Furthermore, if there is true misconduct in the way the organization’s risk areas are managed, the stakes are raised significantly. This means that it’s critical that leaders at all levels convey the gravity of errors and real wrongdoing while also taking them seriously. When disciplinary action is necessary, it should be uniform and fair. Furthermore, there ought to be disciplinary discipline for failure to disclose errors or wrongdoing.
monitoring and auditing. In summary, hospitals should follow the OIG Compliance Program Guidance. According to the OIG, a successful compliance program in the healthcare industry should include regular reporting to top hospital or corporate leaders as well as careful monitoring of the program’s implementation. An official procedure to ascertain whether a process is operating as intended in a particular risk area is auditing. Monitoring is a self-evaluation carried out by a division or department, frequently in response to a remediation plan that was implemented once a problem was identified. In any case, direct audits toward the organization’s high-risk areas, and provide the findings to the governing body.
Reacting to Offenses Found. Examining instances of noncompliance with state or federal legislation constitutes the seventh component of a successful compliance program in the healthcare industry. Explain the launch date and management strategy for the investigations. Talk about the usage of legal counsel and the Compliance Officer’s responsibilities. Indicate how and when reports of possible misconduct or legal infractions should be made to the appropriate authorities. and notify the governing body of the findings of every investigation.
The Conduct Code
One of the other crucial documents for putting healthcare compliance program rules and procedures into practice is a code of conduct. The OIG Compliance Program Guidelines’ requirement for compliance standards for healthcare services is addressed in this policy. Make use of your code of conduct (or code of ethics) to highlight principles that are possibly already addressed in more detail in other policies. Think about having your code of conduct printed by a professional printer. They contain images or pictures that aren’t typically included in official policies. This strategy can remind employees of their duties while also sending a positive message about the organization’s ideals.
The Code of Conduct’s scope
Depending on the type of healthcare institution, the code of conduct’s scope will change. A third-party billing service’s environmental compliance section could not resemble that of a hospital or other provider. However, most rules of conduct address prevalent topics.
Compliance Program and Reporting Requirement
Care and Service Quality
Patient Privacy
Preserving the Resources of the Company
Physician-provider relationships
Charges for Services
Employee Compliance Concerns, such as gifts, conflicts of interest, bribery, or kickbacks
nondiscriminatory setting
Information belonging to the organization is confidential.
Investigations into Environmental Compliance, Marketing, and Advertising, Financial Reporting and Records
disciplinary measures
As with other policies, make necessary updates to the Code of Conduct and make it part of staff training on a regular basis.
It takes courage to implement the policies and procedures of a healthcare compliance program. This is particularly true in a company where sincere self-evaluation and improvement-focused history are either nonexistent or very rare. Nonetheless, a large number of healthcare institutions have created and put into place rules and processes for healthcare compliance programs. These businesses foster an environment where doing the right thing is constantly encouraged. Additionally, there’s a greater chance that people in this culture will aim for superior patient care.
