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Elements of an Effective Compliance Plan for Healthcare Businesses

In the early beginnings of compliance plans for healthcare businesses, big and small, there was a strong suggestion that all healthcare businesses, practices, hospitals and the like adopt a compliance program but there was no directive as to ensuring that a the plan actually worked or was comprehensive enough to ensure the mitigation of potential issues, False Claims Act matters, kickbacks, and the like.   The important part of this in approximately 1998 was to have a plan in place, put it on a shelf and if anyone asked to review it, most practices that did implement a plan would pull it off that shelf, dust it off and provide it to the requester. 

Times have changed.   Healthcare compliance impacts every single health organization, providers and related businesses.   Given the federal government’s enhanced efforts to investigate and audit, the compliance program has taken on even greater importance.   Failure to comply and demonstrate that the compliance program actually works (the healthcare organizations and providers) must be able to show the plan is in effect, includes all basic elements required, is constantly monitored and adjusted to compensate for constant changes in healthcare. 

Failure to comply can result in criminal charges, significant penalties, debarment from Medicare/Medicaid and other health plans.   A healthy, amoebic compliance program can prevent issues and promote legal compliance, ethical compliance and ensure that the businesses and practices meet their obligations associated with ethical matters.

The compliance plan is designed to aid in the reduction and detection of fraud, waste and abuse, pursuant to the HHS/OIG, within the healthcare arena.   The OIG is the primary investigator of health care fraud within the Medicare programs.   Each Medicaid agency is required to investigate Medicaid fraud and abuse, along with the Medicaid Fraud Control Units that exist in the overwhelming number of states.   The MFCU has the ability to prosecute for criminal acts as well as civil violations.  The HHS/OIG has the power to bring criminal charges, impose civil charges and assess penalties which range from just over $11,000 to approximately $23,500 per violation.  

For good measure, the Patient Protection and Affordable Care Act requires “all healthcare organizations to develop and implement formal healthcare compliance programs” while also better definingthe importance of healthcare compliance.    The compliance programs and adherence thereto are a continuous effort to abide by ethical, legal, and standards which exist in the healthcare arena. 

In order to ensure compliance plans are followed, the culture of compliance begins at the top and is mandated from the top through every person in the organization.   There is no level within a practice nor an organization which is immune to compliance.   This will aid in preventing the significant penalties, civil assessments and even criminal charges.    Compliance runs through an organization.  

There are multitude of items which aid in developing and implementing an effective compliance plan for healthcare organizations.   Some of these include:

  1. Developing open lines of communication throughout the organization from the CEO to the Chief Compliance Officer and others in compliance, to supervisors, staff, managers, directors and everyone else not listed
  2. Implementation of comprehensive written policies to be monitored and followed by all employees
  3. Conducting effective and recurring training for all personnel
  4. Naming a Chief Compliance Officer and a Deputy Compliance Officer as well as a Compliance Committee to support the goals of the compliance program and ensure proper focus is placed on complying with what the plan mandates
  5. Ensure that the compliance plan is written and continually updated with all personnel informed of the continuous changes
  6. Conduct recurring audits and investigations to ensure the compliance plan is working correctly
  7. Enforce discipline for those who do not follow the plan, and 8) Taking prompt action when violations of the plan are noted (through audit and investigations), recording the violation and take action to immediately correct and put into place those rules which will prevent a repetition in the future.  

There are many more issues to consider but, since the PPACA mandates this, it is in the best interest of every healthcare organization and practice to take heed, else face the consequences which can be both costly in terms of finance and inability to treat certain patients in the future.    White Collar, llc can be your best friend in ensuring that your plan is in compliance, monitor it for failures and audit/investigate issues which demand corrective action.    We have a combined 100 plus years experience in this area and can make a difference in your practice and/or organization.