Exclusion Screening

What Are the Elements of an Effective Healthcare Compliance Program


Emptech's founder, Jeff Aleixo


Jeffrey Aleixo

Healthcare Compliance Program Elements

Healthcare compliance affects every type of healthcare organization and provider. In light of increased governmental audits and investigations, it is of great importance that organizations establish processes, procedures, and policies as part of an effective healthcare compliance program. Such a program can help them meet the required legal, ethical, and professional standards.

Enforcement actions against healthcare organizations and providers include financial penalties, fines, settlements, and even imprisonment. However, with a defined code of conduct, they can ensure adherence to regulations and requirements and be ready in case of investigations by enforcement agencies.

What Is Healthcare Compliance Program

The aim of the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) is to combat fraud, waste, and abuse in the healthcare industry. The OIG conducts the majority of healthcare investigations and has the authority to impose civil monetary penalties and exclude providers from federally funded healthcare programs. In addition to this, the Patient Protection and Affordable Care Act requires healthcare organizations to develop and implement formal healthcare compliance programs and provides an overview of the role of compliance in healthcare.

One way healthcare organizations can reduce fraud, waste, and abuse liability is through an effective healthcare compliance program. Since compliance programs cannot be designed to fit different types of organizations, the OIG allows creating a program that is adapted to their unique needs. However, it is advisable that every healthcare organization pays special attention to the OIG’s seven fundamental elements of an effective healthcare compliance program.

Seven Elements of an Effective Healthcare Compliance Program

The main focus of every healthcare organization should be promoting a culture of compliance, which includes implementing an effective healthcare compliance program. This allows them to find and correct potential vulnerabilities, reduce the chance of fraud and abuse, and promote safe and quality care. In order to achieve such a level of compliance, healthcare providers and organizations should use the seven core elements as a foundation. These elements can serve as general guidelines to create a culture of compliance and proactively address any compliance shortcomings.

Implementing Written Policies, Procedures and Standards of Conduct

Policies, procedures, and standards of conduct should promote healthcare organizations’ commitment to compliance and address specific areas of risk. They should be clearly written, reviewed, and updated on a regular basis. Furthermore, according to the OIG, this element of a healthcare compliance program should help employees perform their job functions in a manner that ensures compliance with Federal health care program requirements. Also, written policies, procedures, and standards of conduct improve the mission and objective of the healthcare organization.

Designating a Compliance Officer and Compliance Committee

The compliance officer operates and monitors a healthcare compliance program. The compliance committee includes different functions within the organization aimed to support and advise the compliance officer. Designating a Compliance Officer and Compliance Committee prevents, detects, and corrects non-compliance, and supports the organization’s unique structure and compliance program. This element also helps promote standards of conduct and establish a means of communication for reporting non-compliance.

Conducting Effective Training and Education

All members of a healthcare organization should receive training on fraud and abuse laws, as well as the healthcare compliance program. Effective training and education can be achieved by offering compliance training frequently, making training and education part of the job requirements, and staying current on compliance issues and trends.

Find out how to meet different requirements in the healthcare industry and how to solve healthcare compliance concerns with the help of this comprehensive guide.

Developing Effective Lines of Communication

Developing effective lines of communication is an essential mechanism for reporting instances of potential non-compliance. For it to be effective, communication should be accessible, ensure confidentiality, clearly convey the organization’s compliance message, encourage feedback, and provide methods for anonymous reporting.

Conducting Internal Monitoring and Auditing

This element of the healthcare compliance program involves an ongoing process of evaluation and assessment to prevent bad behavior and ensure the effectiveness of education and corrective action. Internal monitoring and auditing include establishing an annual work plan, determining any areas of risk, proactively audit, and review the compliance program. As a result, the compliance program addresses any areas of concern while sustaining compliance program effectiveness.

Enforcing Standards of Conduct through Well-Publicized Disciplinary Guidelines

Standards of conduct outline a healthcare organization’s rules, responsibilities, proper practices, and expectations of its employees. To ensure an effective healthcare compliance program, standards should be followed continuously and consistently throughout the organization by all personnel regardless of position, title, or rank.  

Responding Promptly to Detected Offenses and Undertaking Corrective Action

Failure to ensure timely and effective remedial action for offenses can create additional exposure for the organization. Effective ways to address offenses include developing a method for tracking and responding to compliance issues, thoroughly documenting and investigating, enforcing corrective action, and tracking the resolution of complaints. Also, undertaking the appropriate corrective action is crucial for maintaining an effective healthcare compliance program.

Establishing Culture of Healthcare Compliance

A healthcare compliance program involves a continuous process of adhering to legal, ethical, and professional standards applicable to healthcare organizations and providers. It requires constant development of processes, policies, and procedures to define appropriate conduct, educate staff, and ensure proper application of guidelines. An effective healthcare compliance program can help protect organizations against fraud, abuse, waste, and other potential liability areas. Otherwise, they can face increased violations or enter into a Corporate Integrity Agreement with the OIG.

Healthcare organizations should promote a culture of compliance at all levels. As a result of an ongoing process, the healthcare compliance program needs to be proactive and change with the needs of the healthcare organization. Whether healthcare organizations are creating or accessing healthcare compliance programs or looking for a way to prevent privacy and security pitfalls, compliance challenges can be solved with an electronic solution. Exclusion screening software ensures that healthcare organizations adhere to compliance guidelines and revise compliance practices based on changing regulations. Thus, healthcare organizations of all sizes avoid violation fines, reduce the costs and resources necessary for creating an effective healthcare compliance program, and improve the delivery and quality of healthcare services.

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