Exclusion Screening

Understanding Healthcare Compliance


Emptech's founder, Jeff Aleixo


Jeffrey Aleixo

healthcare compliance OIG regulations

Healthcare compliance involves meeting the standards set for the legal, ethical, and professional operation of healthcare organizations. Since healthcare is one of the most regulated industries in the United States, achieving healthcare compliance is a complex and time-consuming process, but also necessary. 

With increasing regulatory pressures on healthcare organizations, there has been a rise in enforcement activity by the federal government, aimed at identifying fraud, waste, and abuse in the healthcare industry. Therefore, healthcare compliance needs to comply with healthcare regulations, requirements, and standards, but also promote prevention, detection, and resolution of conduct that does not conform to these requirements.

Developing a Compliance Plan

Managing healthcare compliance effectively requires a compliance plan that is in accordance with changing government regulations, payer requirements, office operations, and technology. An effective compliance plan helps an organization achieve compliance goals and should encompass all areas of regulation applicable to the healthcare organization.

Implementing a well-designed compliance program ensures proper payment of claims, minimizes billing mistakes, helps protect patient privacy, and reduces the chances of an audit. In addition to this, it helps to comply with the self-referral and anti-kickback statutes.

Apart from this, a compliance plan encourages employees to report erroneous conduct, so that mistakes may be corrected promptly. Such a compliance policy helps employees understand that although billing errors sometimes occur, it is everyone’s responsibility to be informed about the compliance rules and to take necessary steps if errors happen in order to mitigate risk.  

The Office of Inspector General (OIG) Work Plan is an excellent resource for healthcare providers to build their compliance plan since it provides detailed information regarding audit results from the previous months and years. OIG’s Work Plan summarizes new and ongoing reviews and activities that the agency plans to pursue in accordance with the U.S. Department of Health & Human Services (HHS) programs and different projects that are planned in the near future. 

Use this comprehensive guide to find different rules, regulations and standards that apply to healthcare organizations and providers and find the right way to build an effective healthcare compliance program.

The Seven Elements of an Effective Healthcare Compliance Program

The OIG sets minimum standards that all compliance programs should include. The following are seven critical elements that should be included in any comprehensive compliance program, according to the OIG:

  1. The development, distribution and implementation of written standards of conduct and written policies and procedures that describe and further the organization’s commitment to meeting and exceeding the legal and ethical standards applicable to the organization,
  2. The designation of a chief compliance officer and other appropriate committees and individuals that are responsible for operating and monitoring the compliance program and who report directly to the organization’s chief executive officer and the governing body,
  3. The development and delivery of effective employee education and training programs,
  4. The development and maintenance of effective lines of communication that allow individuals to report compliance concerns without retaliation, including the ability to anonymously report concerns and complaints,
  5. The development and implementation of a process to respond to complaints that includes the imposition of appropriate corrective action including discipline of employees when required,
  6. The use of internal monitoring and audits to measure compliance and address known deficiencies, and
  7. Responding appropriately and quickly to detected offenses and implementing corrective action.

Every effective healthcare compliance program needs to address the seven elements listed above to mitigate risk areas. However, an effective healthcare compliance program must also include other regulatory compliance areas applicable to healthcare organizations or providers. As the regulations applicable to the healthcare organization change, its compliance program should change as well.

Find out how to ensure lower payments, faster resolution and release from further compliance obligations by taking the initiative to inform OIG of any violations of the law under the OIG’s Self Disclosure Protocol.

Achieving Effective Healthcare Compliance

Staying on top of regulatory compliance is essential for today’s healthcare providers. Having a strong compliance program in place not only helps protect organizations from financial and regulatory risk but also contributes to the creation of an ethical environment that provides safe and quality care to patients.

It is essential to have a compliance program that keeps up to date with the regulatory environment and its changing rules and regulations. A well-prepared healthcare organization with a sound compliance program should not wait until there is an investigation to review compliance policies. Instead, it should conduct regular risk assessments of its business practices and take a close look at the environment in which it is operating to see whether updates or changes need to be made. Compliance begins with a thorough assessment designed to identify gaps and vulnerabilities in existing policies. Until an organization understands where its compliance risks are, its compliance program cannot perform its vital function of mitigating potential regulatory risks. 

Now more than ever, healthcare organizations should take a closer look at their compliance programs to ensure they are strong enough to prevent the types of exposures that lead to investigation and prosecution. Healthcare providers have to regularly review and update compliance plans with new laws and regulations coming from all levels of government. Finally, they need to adopt modern technologies and processes to achieve healthcare compliance together with overall cost reduction and efficiency. 

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