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The Importance of "Effective" OIG Compliance Programs

The Importance of "Effective" OIG Compliance Programs

Development of policies and procedures and training to comply with the Health Insurance Portability and Accountability Act (HIPAA) and the Occupational Safety and Health Administration (OSHA) are two of HCP's most common requests from clients. While these two programs are essential components of compliance in the healthcare industry, they are not the only components.

Over 11 years ago, the Affordable Care Act of 2010 mandated a compliance program as a condition for enrollment in federally funded programs like Medicare and Medicaid. Yet, this is still an area that many healthcare organizations do not fully understand and have not implemented appropriately. According to the US Sentencing Guidelines, an "effective" compliance program shall:

(1) exercise due diligence to prevent and detect criminal conduct; and

(2) otherwise, promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law.

The Office of Inspector General (OIG) has provided resources to assist healthcare organizations with developing an effective compliance program. Two publications of particular interest to healthcare providers are:

The Compliance Program Guidance for Individual and Small Group Physician Practices (2000)

Compliance Program Guidance for Third-Party Medical Billing Companies (1998)

Preventing potentially fraudulent activity is the priority of an effective compliance program, but there is an additional benefit to put a program in place. Based on the US Sentencing Guidelines, there can be up to a 95% reduction of fines if an "effective" program was in place prior to the detected misconduct.

An "effective" compliance program is scalable. There is no one-size-fits-all. Compliance should be "woven into the fabric of routine operations." This means that compliance is incorporated into daily operations and is demonstrated by all members of the organization from the top down.

What's Included in an Effective Compliance Program

An effective compliance program, as defined by the OIG, includes seven elements. Listed below are each of the elements along with implementation steps:

1. Standards and Conduct

  • Assess risk areas and implement policies and procedures to reduce risks
  • Obtain commitment from each Board member and/or owner
  • Create an organizational Compliance Culture (Code of Conduct)

2. Oversight

  • Designate Compliance Officer and Committee with roles and responsibilities
  • Provide clear lines of communication to Board and defined reports
  • Present compliance activity reports to Board (Compliance Committee Meeting)

3. Education and Training

  • Develop training and education specific to the job tasks
  • Use real cases specific to the organization
  • Utilize HCP resources and HEAT videos

4. Reporting

  • Develop effective communication lines
  • Use anonymous reporting (hotline 24/7) (available through HCP)
  • Implement 'no retaliation' policy for good faith reporting

5. Monitoring and Auditing

  • Monitoring should be a part of daily operations
  • Drill down into problem areas
  • Schedule follow-up audits with external auditors (CRA/Audits)

6. Enforcement and Discipline

  • Implement a Discipline Policy for noncompliance
  • Demonstrate level playing field with discipline enforcement

7. Response and Prevention

  • Respond promptly to detected offenses
  • Take action on all reports
  • Follow-up with appropriate communications
  • Implement corrective actions / monitor improvements

HCP has several resources available to assist your organization with the development of an Effective Compliance Program. If you are an existing client and have additional questions about implementing a compliance program in your organization, reach out to your HCP Support Team. If you are not a client and would like more information about the services available to you from HCP, click here.