In a high-risk industry like healthcare, the process of following rules, regulations, and laws related to healthcare is of utmost importance. Healthcare compliance covers a wide range of practices, exclusion screening, internal and external rules, and issues such as patient safety, the privacy of patient information, and billing practices.
Every healthcare organization needs to have effective healthcare compliance to operate efficiently and provide safe, high-quality patient care. Noncompliance with the Department of Health and Human Services (HHS), Office of Inspector General (OIG) can result in significant consequences. Possible penalties for violating state or federal laws or submitting fraudulent claims can include:
- Exclusion from Medicare and Medicaid programs;
- Completion of a Corporate Integrity Agreement;
- Civil and criminal penalties; or
- Referral to the provider’s state medical board.
Effective Healthcare Compliance
Changing laws and regulations can make it difficult for organizations to keep up with healthcare compliance. In addition to this, laws differ between states while compliance issues and needs differ between organizations depending on their size and resources.
The Office of the Inspector General has many different resources for healthcare compliance. Along with educational materials, the OIG outlines elements of effective healthcare compliance that are used as a guide for healthcare providers and organizations in the process of developing their own compliance programs. The seven fundamental elements are:
- Implementing written policies, procedures, and standards of conduct,
- Designating a compliance officer and compliance committee to provide program oversight,
- Using due diligence in the delegation of authority,
- Educating employees and developing effective lines of communication,
- Conducting internal monitoring and auditing,
- Enforcing standards through well-publicized disciplinary guidelines, and
- Responding promptly to detected offences and undertaking corrective actions.
Auditing and Monitoring
The OIG repeatedly emphasizes the importance of auditing and monitoring activities in its various guidance documents as one of the most important metrics of how effective healthcare compliance is. Auditing and monitoring are key controls for the identification of areas that require improvement within a healthcare organization while simultaneously ensuring the existing systems are error-free.
According to the OIG, auditing and monitoring should be an ongoing process necessary for a successful compliance program. However, the OIG does not define the differences between the two terms, and addressing ongoing auditing and monitoring remains a major challenge for compliance officers.
Auditing is a systematic and objective assessment that is designed to evaluate and improve the effectiveness of a healthcare compliance plan. Audit objectives are to review the ongoing monitoring process and to ensure that policies, procedures, and controls adopted are adequate by validating their effectiveness through reduced errors and risks. The key element of successful auditing is objectivity. Therefore, it has to be performed by reviewers independent of the process that is being audited. Also, the audit should be accompanied by a report that specifies recommendations for corrective actions, if necessary.
Monitoring is a continuous process aimed to detect compliance risk issues associated with an organization’s operations. It is usually performed by a management team that ensures developing internal policies and procedures to comply with changes in regulations and applicable laws and takes necessary steps to monitor and verify compliance with these guidelines. The monitoring process is usually less structured than auditing, and, while auditing is conducted yearly, monitoring should be performed weekly or monthly.
The OIG Work Plan
An initial step in auditing and monitoring is to determine what standards and procedures apply to different healthcare organizations. The OIG Work Plan is an excellent resource for providers and healthcare organizations that can be used as a foundation for risk assessment. It provides detailed information regarding audit results from the previous year and summarizes the U.S. Department of Health & Human Services (HHS) programs and operations planned during the current and following years. As such, it can be a useful tool for identifying areas of risk that are in focus and if any of them apply to different healthcare practices.
Using Technology to Strengthen Compliance
Given that healthcare is one of the most complex and highly regulated industries, the government’s regulatory steps constantly evolve, requiring healthcare organizations to develop with them. To do so, compliance programs must include constant monitoring and auditing that allows resolving issues quickly and appropriately as they arise. However, healthcare providers and organizations need to integrate technology in their compliance programs to ensure medical data privacy and security, increase efficiency, and improve accuracy and risk management.
Auditing and monitoring are some of the most critical elements of healthcare compliance because they evaluate whether internal controls are adequate and productive. Healthcare compliance software that includes auditing tools simplifies the entire process. By keeping all the data in one central location, auditing software makes it easy to identify high-risk areas. As a result, organizations can run risk assessments, find gaps in compliance, and address potential risks before they get out of hand.
Between changing industry standards, and federal, state, and local laws and policies, it can be difficult to maintain compliance in healthcare and provide patient safety and care, while avoiding costly lawsuits. However, healthcare compliance software can help organizations achieve and maintain compliance with fewer resources, track changing regulations, and save organizations thousands of dollars in the long run by preventing regulatory fines.
Ultimately, healthcare organizations can put focus on high-quality patient care, and not just on maintaining compliance.