Healthcare organizations have to meet a variety of regulatory and legal standards. While this process can be very complex, compliance with the Office of Inspector General (OIG) regulations is necessary to mitigate risk for healthcare providers and organizations. In addition to having a compliance program, healthcare organizations also need to measure their effectiveness.
An effective healthcare compliance program is essential for every organization because it helps reduce fraud and abuse, enhances healthcare provider operations, improves the quality of services, and reduces overall costs. To that extent, healthcare organizations can use OIG compliance guidance documents to prepare and gain insight into how investigators evaluate healthcare compliance program effectiveness.
OIG Compliance Guidance Background
Developing and implementing an effective compliance program is critical for all healthcare organizations, and to help them create and maintain such programs, OIG issued a Resource Guide for Measuring Compliance Program Effectiveness. OIG compliance guidance was developed through a collaborative effort with the Health Care Compliance Association (HCCA). Thus, they provided metrics for measuring compliance program effectiveness for a wide range of healthcare organizations differing in size, operational complexity, industry sectors, and resources.
The purpose of the Resource Guide is to give healthcare organizations different possibilities for measuring the effectiveness of their compliance programs, by choosing which metrics best suit their needs. Therefore, this OIG compliance guidance is not designed to be a checklist or applied in its entirety. Instead, healthcare organizations should select only those metrics that fit their needs, resources, and risks.
Content of OIG Resource Guide
The Resource Guide contains a long list of questions that healthcare professionals can use to identify how to measure the effectiveness of their organizations’ compliance programs. OIG compliance guidance encourages healthcare organizations to establish a program that meets seven specific criteria, which are commonly called the seven elements of an effective compliance program.
The seven elements range from the designation of a compliance officer and the establishment of a compliance committee to ensuring that organizations consistently apply disciplinary procedures. Also, if an organization comes under investigation by OIG or the U.S. Department of Justice (DOJ), the existence of an effective compliance program can help mitigate the effects of the conduct and prevent future similar actions in numerous ways.
The seven key areas identified in the Resource Guide are:
Standards, Policies, and Procedures
This section highlights the importance of having the relevant policies and procedures in place to form the structure of an organization’s compliance program. This refers to measuring employees’ access to the policies, implementing internal processes for periodically reviewing the policies, and assessing the quality and applicability of the policies. Also, healthcare providers need to maintain an organizational code of conduct and ensure an understanding of compliance policies and procedures across their organizations.
Compliance Program Administration
The metrics highlighted in this section of the Resource Guide provide ideas for evaluating the effectiveness of an organization’s board of directors, compliance committees, compliance officers, compliance staff, and general culture of compliance. According to OIG compliance guidance, a key component of an effective compliance program is a well-functioning administration that involves everyone in an organization.
Screening and Evaluation of Employees, Physicians, Vendors, and Other Agents
The questions in this section focus on how well organizations evaluate employees, vendors, and affiliated individuals for possible exclusion and conflicts of interest, and whether they have a plan for responding to these issues. This part of OIG compliance guidance emphasizes that organizations should be aware of their obligations with respect to vendors, agents, and affiliated individuals as well as their employees.Use this detailed guide to stay ahead of different rules, regulations, and standards that apply to healthcare organizations and find the best approach to building an effective healthcare compliance program.
Communication, Education, and Training on Compliance Issues
Identifying if individuals receive effective job-appropriate training, an organization’s governing body is adequately trained in compliance efforts, and training is updated with regulatory changes or compliance failures is another important part of the Resource Guide. This section of OIG compliance guidance also points out the importance of establishing a culture of compliance.
Monitoring, Auditing, and Internal Reporting Systems
An integral part of a compliance program is evaluating the effectiveness of processes for monitoring violations of laws and regulations, an internal reporting system for noncompliance, as well as risk assessments and compliance audits. This section also highlights the importance of responding to compliance audits or instances of noncompliance, including corrective action plans.
Discipline for Non-Compliance
This section focuses on whether an organization’s policies on corrective action are fair and followed consistently throughout the organization. This helps organizations assess whether if employees and associates are aware of the corrective action procedures and whether incentive and promotion criteria are appropriately aligned with compliance concerns.
Investigations and Remedial Measures
This section of OIG compliance guidance includes metrics that organizations may use to evaluate the effectiveness of compliance investigations. This refers to the independence and competence of the investigators, communication regarding investigations, and appropriate response to identified compliance concerns.
Putting OIG Compliance Guidance to Use
Developing and implementing an effective compliance program is critical for healthcare organizations in order to identify areas of risk and respond to issues as they arise. While OIG compliance guidance cannot fit every compliance program framework, healthcare organizations can apply these metrics based on their risk areas, size, resources, and industry segment. Furthermore, applying appropriate elements from the Resource Guide helps organizations demonstrate that they are taking necessary measures to meet their goals and mitigate penalties in the event that problems do emerge.
Apart from OIG compliance guidance, healthcare organizations can use other resources when developing compliance programs, such as specific compliance program guidance documents, OIG Work Plan active items, and corporate integrity agreements. Also, healthcare organizations can further simplify compliance challenges with exclusion screening software and reduce potential risks while setting higher standards when it comes to adhering to the OIG standards.