HEALTH CARE COMPLIANCE 1 (HEALTH INFORMATION MANAGEMENT)
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Chapter_8_-_Compliance_Program-1.pptxChapter 8
Compliance Programs in General
Learning Objectives (I)
Benefits of a comprehensive compliance program
Contribution of Federal Sentencing Guidelines
7 standard compliance program components
Roles of Compliance Officer and Committee
Purpose of compliance policies and procedures
Outline of a compliance training initiative
Learning Objectives (II)
Open communication channels for questions and complaints
Compliance auditing and monitoring methods
Disciplinary program for employee misconduct
Investigation of suspected non-compliance
Introduction
In order to ensure obedience to the large and growing number of laws impacting health care, every health care entity must have a compliance program.
Such a program is an infrastructure of rules, trainings, penalties, and response protocols that reduces the incidence of non-compliance, detects it faster when it happens, and prevents its recurrence.
Introduction
Under the PPACA of 2010, compliance programs are mandatory.
Benefits of a Compliance Program (I)
Prerequisite to Medicare program participation
Demonstrates good corporate citizenship
Method for eliminating misconduct and illegal behavior
Clearinghouse for information on legal and payor requirements
Encourages employees to report misconduct
Protocol for investigating and resolving misconduct
Benefits of a Compliance Program (II)
Reduced exposure to a wide range of civil and criminal legal penalties
Enhanced public image and reputation
Required improvement in operations
Insight into employee attitudes and behavior
Ability to react to reports of misconduct
Better cooperation among health care entities
Employees empowered to question and report
7 Components of a Mandatory Compliance Program
Written standards of conduct, policies & procedures
Designation of Compliance Officer & Committee
Regular compliance training programs
Open channels to receive questions & complaints
Ongoing audits and monitoring for effectiveness
Disciplinary action for violations & non-compliance
Investigation and corrective action for non-compliance
8
Compliance Officer
Single person with overall responsibility for management of the compliance program
Full-time job, reports directly to CEO, and has access to the governing board
Coordinates investigations of misconduct and resulting corrective actions
Interacts with legal counsel and government agencies on compliance matters
Compliance Committee
Advisor to Compliance Officer, hear appeals of his decisions, perform more substantive tasks
Composed of people from compliance-related areas (legal, billing, personnel, security)
Written Standards, Policies and Procedures
Guide the conduct of organization and employees in day-to-day operations
Provided to employees, physicians, and agents
#1 Code of Conduct
#2 Policies and procedures describing general principles of work behavior
#3 Policies and procedures describing job performance in high compliance risk areas
Code of Conduct
A kind of “constitution” stating the basic values and principles that employees are expected to follow
Should be brief, quickly understood, memorable, and applicable to all employees and agents
Reflection of the character of the organization
Code of Conduct
Sign to the public of the organization’s good citizenship and worthiness as a source of health care good or services
Tells suppliers, vendors, agents that organization is a high-integrity, trustworthy business partner
General Policies and Procedures
States organization’s commitment to abide by the external requirements and constraints imposed on it, including laws focused on the health care industry, other laws (employment discrimination, environmental protection) that apply to all businesses, and the requirements for participation in Federal health care programs like Medicare and Medicaid.
Specific Policies and Procedures
Tells employees working in areas at high risk of non-compliance how to perform their jobs.
The OIG Program Guidances describe risk areas for each type of health care organization and suggest policies to address the risks.
Review guidances from exemplary health care organizations like hospitals or physician practices.
Implementation of Standards, Policies, and Procedures
Must be communicated to and understood by employees who will apply them.
Take into account employees’ languages, education levels, and backgrounds.
Know basic compliance principles by heart.
Employees acknowledge their receipt and understanding of the rules, and their agreement to follow them.
Compliance Education and Training
Appropriate training to employees when first hired and at regular intervals thereafter
Curriculum topics – basic and advanced
Training attendance is condition of employment & a factor in evaluations
Directed at all employee levels of organization
Try to reach vendors and contractors as well
Use variety of teaching methods
Communication Channels for Questions and Reports
Employee seeks compliance clarification
Employee reports of suspected misconduct
Work environment that encourages employees to talk about problems
Multiple channels for compliance reporting
Employee reports kept confidential, no retaliatory discipline
Publicize the communication channels
Monitoring and Auditing of Compliance Activities
Monitoring - persistent review of activities in the course of normal day-to-day operations
Auditing - more formal, discrete review of compliance with a select criteria
What activities to monitor or audit
Methods for gathering operational data relevant to compliance
Using the data gathered by monitoring and auditing
Disciplinary Action Against Non-Compliant Employees
Range of culpability for non-compliance
Investigate incidents
Stop the non-compliant activity
Identify responsible persons
Take appropriate disciplinary action
Formal system for administering discipline
Ensuring compliant behavior of agents
Investigation Followed By Corrective Action
Prepare protocol for conducting investigations
Person to lead & conduct the investigation
When attorney and experts get involved
Evaluating investigation progress and ending it
Protecting information security and anonymity of individuals involved
Decision on corrective action
Possible Corrective Actions
Discipline of employee, termination of agent K
Repayment of overpayments received
Report of non-compliance to government
Report incidents to law enforcement agencies
Reengineer faulty internal systems
Revise education and training curriculum
Retrain relevant personnel or hire new ones
Modify existing policies and procedures
Health Care Industry Compliance Practices
Compliance training is mandatory
Most common training methods
Measure compliance program effectiveness
Set goals for compliance programs
Areas covered by compliance programs
Organization status of Compliance Officer
Compliance Committee responsibilities
