A healthcare compliance program is recognized to entail a continuous process that adheres to legal, professional, and ethical standards that are applicable to healthcare providers and organizations. Every type of healthcare provider and organization is affected by healthcare compliance. Healthcare organizations should establish procedures, processes, and policies as a part of a healthcare program that is effective; this should be done in light of increased investigations and governmental audits. Enforcement actions against providers and healthcare organizations are imprisonment, financial penalties, settlements, and fines.
In the Department of Health and human services (HHS), the Office of the Inspector General (OIG) aims to ensure that constant abuse in the healthcare industry, fraud, and waste is reduced. Most healthcare investigations and the power to impose civil monetary policies are usually conducted by the Office of the Inspector General (OIG) (Demske et al., 2018). The OIG also has the power to the exclusion of healthcare providers from the programs that the federal government funds. According to the patient protection and Affordable act, various healthcare organizations are required to develop and facilitate the implementation of formal healthcare compliance programs. In addition, patient protection and the Affordable Care Act are responsible for the provision of an overview of the healthcare compliance roles. Even though compliance programs cannot be modified to fit the needs of various healthcare organizations, therefore the OIG allows program creation that is well adapted to the required needs of various organizations.
Compliance program serves the role of promoting organizational adherence to state and federal law and private-payer healthcare requirements that are applicable. A compliance program that is effective will help in the protection of the practices that are against abuse, fraud, waste, and other areas identified to pose potential liabilities. Medical practices are recommended to establish a compliance program under the affordable care act as an enrolment requirement in the Medicare program. Therefore, healthcare providers are currently required by commercial health carriers to have compliance as a participation technique.
During the creation and modification of the various healthcare compliance program, it is recommended that each organization should pay special attention to the seven fundamental elements of OIGs. The elements are meant to serve as guidelines for the creation of a compliance culture that is recommended for proactively addressing any compliance shortcomings.
- Implementation of the written procedures, policies, and standards of conduct. Taking these actions ensures that various risk areas are addressed accordingly. The policies and procedures should be written clearly and updated on a regular basis.
- Designation of the compliance committee and officer. This element is meant to ensure that the compliance program is operated and monitored accordingly. Additionally, through this element, standards of conduct can be promoted and reporting of non-compliance can be made easy.
- Adopting an effective communication line that is accessible, confidential, and appropriately conveys an organization’s compliance message.
- Conducting effective education and training on abuse, fraud, and laws and the compliance program to all members within a healthcare organization.
- Conduction of internal auditing and monitoring such as identification of any risk areas.
- Prompt response to the offenses detected and considering corrective actions.
- Enforcement of standards of conduct through the establishment of disciplinary guidelines that is well publicized.
The below signatures affirm the validity and effectiveness of the compliance program. Therefore, it is effective for any healthcare organization and should be utilized appropriately.
Compliance Program: General Standards of Conduct
All Healthcare Personnel Are Advised to Strictly Adhere to the Standard Code of Conduct Every Time. For Any Individual Who Has Reasonable Grounds to Believe That a Colleague Has Violated the Outlined Codes, the Compliance Committee Is Open to Such Communication That Is Based on Facts.
- Workplace environment and behavior; medical personnel should treat every individual with courtesy, dignity, and respect. Each healthcare personnel should recognize that they are the greatest strength of an organization and therefore they should be committed to the success of their work.
- Each medical personnel should observe punctuality and work productively while on duty.
- Employees should adhere to the policy of overtime.
- While performing, their duties medical personnel should ensure that they always maintain fairness, honesty and integrity while performing their duties.
- Healthcare personnel while at work, should refrain from using social media as this is a hindrance to the quality of service.
- Privacy and Confidentiality; healthcare personnel shall be committed to maintaining patient confidentiality as per the ethical and legal standards. There will be no tolerance of breach of the client’s confidential information.
- Practice personnel shall conform to all established laws, privacy policies and confidentiality.
- The privacy of all healthcare organization clients, fellow employees, visitors, and medical staff shall always be respected.
- No discussion of other patients’ details or medical records with or in front of other clients.
- Safeguarding the resource and assets of the organization. The properties should be protected against theft, loss, and misuse.
- Ensuring the safety of the environment for the benefit of every individual within the organization.
- Conflict of interest; healthcare personnel should conduct their roles on behalf of the medical organization and that of the patient, this should not be interrupted by outside or personal interests.
- Full devotion of ability and time to the duties of the organization during working hours.
- Actual or potential conflicts should be reported to the manager.
- Quality of care and service; the practice personnel shall ensure that the client visiting the healthcare organization receives the highest quality and most reliable services.
- Employees should ensure that the care administered to a patient conforms to acceptable safety and clinical standards.
- There should be the provision of timely and appropriate care to all clients without any form of discrimination such as racial, religion, gender, age, political status, or disability.
- There should be a continuous strive toward a culture of patient safety by the practice personnel.
- Maintenances of thorough and complete records of various clients’ information as per the applicable regulations and laws and accreditation standards.
Each healthcare personnel is required to respond with a sign upon reviewal of the standard conduct.
Acknowledgement of the general standard of conduct. (Healthcare personnel)
Name of the employee.
I have reviewed and understood the outlined general standard of conduct and failure to do that, I shall stand to face the repercussions.
Compliance Program: Administrative Responsibilities
The Administrative Ensures That the Healthcare Practice Is Conducted as per the Effective Compliance Program, Additionally, in Coordination With the Members of the Compliance Committee and an Officer Who Is Qualified. The Administrator Receives Regular Reports and Guarantees That the Organizations Abide by the Compliance Program.
How the administrator will ensure that the purpose of the compliance program is fulfilled.
- In charge of overseeing the activities of the compliance committee and officer and making rational decisions appropriately (Doyle, 2019).
- The administrator and other members within the administrative body, are usually members of the compliance committee.
- Managing the healthcare experience of the patient as per the compliance program.
- The body is responsible for maintaining confidentiality in accordance with the compliance program, number CP 002.
- The administration should ensure every individual undergoes the appropriate training on the healthcare practice as stipulated in the compliance program.
- The administrative body should also ensure that the patients receive quality service and care as per the compliance program, CP 006.
- In case of violation of the laws, rules, and regulations outlined in the general standard conduct of the compliance policy, appropriate steps are to be taken or considered.
Compliance Program: Compliance Officer Responsibilities
For an Appropriate Compliance Program, the Existing Compliance Officer Should Be Effective in Coordination, Monitoring, and Coordinating the Actions of the Compliance Committee. The Compliance Officer Is Responsible for Meditating Between the Compliance Committee and the Administrative Personnel.
After appointment by the governing board, the compliance is responsible for:
- Auditing and interpreting the reports to various departments.
- Is answerable to the administrator and therefore communicates all the activities taking place within the compliance program.
- Responsible for coordination, reviewing, and updating the existing healthcare policies and procedures.
- Ensures that the filing deadlines and the regulatory reporting guidelines are as per the compliance program CP 005.
- Development of programs that are meant to train and educate the healthcare personnel as per the compliance program.
Compliance Program: Employee Responsibilities
Employees Are to Adhere to General Standard Policy to Ensure the Safety of Themselves and the Patient. They Are Advised to Report Any Violation of the Laws and the Rules of the Compliance Program. The Employees Are Recommended to Concentrate on Their Line of Duty for Proper Service Delivery Within the Organization.
- Corporate with the administrative body to ensure that they undergo proper training that qualifies them for their appropriate positions.
- Protect the properties of the organization as outlined in the compliance program CP 003
- Be corporative and provide any necessary assistance to the compliance officer that facilitate the implementation of various rules and guidelines.
- Should be aware of the repercussion upon violation of the laws and the rules highlighted in the general standard policy.
- When on duty, are expected to avoid using their phones on social media as per the compliance program CP 001
- To avoid any form of discrimination as outlined in the compliance program CP 006
- Employees are expected to adhere to safety manual work for the safety of the patients, other employees, and the organization’s facilities.
- The employer should minimize or possibly control any situation that may pose harm to the employees.
- In coordination with the compliance officer and the administrative body, the employees should ensure that they are provided with the appropriate protective gears to minimise exposure to life-threatening conditions.
- The right not to be disciplined when absent from work considering the reasons behind that are reasonable.
- The employees have the right to discuss with the compliance officer and the administrative body the health and safety concerns that they have to avoid future inconveniences.
Compliance Program: Medical Staff Responsibilities
The Medical Staff Is Expected to Prioritize Their Duties by Maintaining Ethical and Professional Standards. The Medical Personnel Is Expected to Administer Quality Services to the Patients at All Times. It Is Their Responsibility to Report a Colleague Is Against the Code of Ethics.
- Are recommended to act as per the compliance program CP 001, showing respect and dignity to their clients.
- As outlined in the compliance program 002, medical personnel are expected to maintain confidentiality and privacy on patients’ records. Through this, they are able to abide by ethical conduct.
- Engage in continuous education and training as per the recommended line of work. Medical personnel should be up to date with the current practices that lead to quality healthcare in the field of medicine.
- As per compliance program 006, medical personnel should adopt practices that are for the benefit of the patient.
- Reduction of social isolation among patients and assisting them in the navigation of the social service and healthcare system. Additionally, the medical personnel should manage care and transition in healthcare among the vulnerable groups.
- Ensure the safety of the patients and themselves through the use of personal protective equipment (PPEs).
Compliance Program: Education and Training
All Employees Within the Healthcare Organization Will Be Able to Deliver Quality Service When Engaged in Proper Training and Education. There Will Be an Increased Competency Rate Among Various Healthcare Personnel. With Proper Training, the Compliance Officer Will Be Able to Update Laws and Regulations Favorably to Suit the Organization’s Needs.
- Special type of training should be conducted for various individuals from different departments. For instance, compliance officers and medical doctors are two individuals in different specialties and, therefore should be considered for specialized training. The compliance officer should be updated on modernized computations and software for efficiency during work.
- All employees should receive training, especially during the onboarding process. This is to familiarize the new employees with the culture of an organization. Training will enable them to act in accordance with the provisions in the compliance program. Some of the areas that are critical to consider in training;
- The organization structure to understand the protocols that exist in the institutions
- The facilities and the location of each of the basic equipment
- The potential sanctions should not be committed as they are violations that come at cost.
Compliance Program: Communicating Compliance Issues
Every Individual in the Healthcare Practice Should Be Made Aware of the Existing Compliance Program and Its Contents. Communication or Creating Awareness of the Contents of the Compliance Program Is a Sure Way to Ensure That There Is a Reduction in Fraud and Abuse Within an Organization.
For a proper understanding of the contents of the compliance program, there are some issues that must be elaborated on:
- Steps to consider in case of fraud or abuse of clients within a healthcare setting. The compliance officer should be made aware; the matter will then be taken to the compliance committee upon notification of the administrator. With that knowledge, most healthcare personnel will know the proper protocol to follow.
- The compliance officer should be able and available to clarify where necessary concerning various issues on legal and ethical regulations. From these questions, the compliance officer can also come up with other rules that can be helpful.
- Through the compliance program, employees will be aware of the procedures of reporting various violations as per their degrees.
Compliance Program: Auditing and Monitoring
During Auditing and Monitoring, Activities on the Performance of the Various Employees in Their Specialized Sectors Will Be Monitored as per the Compliance Program. The Monitoring Will Be Based on a Periodic Basis and the Results Will Be Collected by the Compliance Officers, the Administrator, and the Compliance Committee Will Be Updated on the Progress of the Activity.
- The individual who will be in charge of the auditing and monitoring is the compliance officer who, with the aid of the compliance committee, will be able to coordinate the activity. The compliance officer will appoint various individuals from different departments to assist in the process.
- There are several concerns or issues that will be reviewed by various departments and healthcare personnel on a regular basis. These are:
- The patient’s feedback on the services provided
- The competency level of various healthcare personnel
- The violation on items against the compliance program
- The report on the violations against the compliance program should be made on a predetermined period of time, for instance, annually or twice a year.
- After the completion of the internal audit, external audients should take a frame to ascertain the accuracy of the initial assessment.
Compliance Program: Investigation of Response
The Compliance Officer Will Be Able to Conduct the Investigative Process on the Result of the Findings Made During the Auditing and Monitoring Process. After the Investigation, the Cause of the Problems Will Be Identified and the Correct Step Will Be Taken or Will Be Recommended to Avert Future Mistakes.
- The obtained report can be utilized as a corrective measure to the violations that initially existed. Errors among the healthcare personnel and in the department can be traced to various issues that can be identified and addressed.
- To identify the errors that occurred, the compliance officer will do an analysis of every piece of data collected and identify the frequencies. This can be done through computation skills by the compliance officer or through specialized personnel.
- The compliance officer will then report the identified source of the mistakes to the relevant authorities, such as the compliance committee and the administrator.
- Relevant solutions to the problems can then be formulated through the compliance committee.
Compliance Program: Billing Responsibilities
A Billing Compliance Plan in the Field of Healthcare Is Recommended to Avoid Potential Abuse and Fraud as the Claim That Is Made in the Hospital Billing and Coding Program Is Justified.
- Involves integration of the compliance actions in various hospital-specialized areas.
- The service also aims to confirm the organization’s documentation or medical necessity.
- The healthcare personnel and compliance officer involved ensures that their presented claims are within the state and federal laws.
- According to Billing and Coding Compliance (n.d), physicians and other healthcare personnel should we equipped on the appropriate skills and expertise through training and education.
Billing & Coding Compliance (n.d). UC San Diego Health Sciences.
Demske, G. E., Taylor, G., & Ortmann, J. (2018). Shared Goals: How the HHS Office of Inspector General Supports Health Care Industry Compliance Efforts. Mitchell Hamline L. Rev., 44, 1145.
Doyle, L. (2019). Healthcare Administrators: Roles, Responsibilities, and Career Outlook. Northeastern University.