What Are The Elements Of An Effective Healthcare Compliance Program?

Some of these have far-reaching implications, such as the Anti-Bribery Statute, the Stark Acts, the False Claims Act, and the HIPAA and HITECH laws designed to protect the privacy of patient information. To meet health care compliance, organizations need a health care compliance plan, including written policies, procedures, and standards of conduct. By being aware of these six issues, your healthcare organization can build a comprehensive and proactive healthcare compliance program. Contact our team today to learn more about 1st HCC’s healthcare compliance management solutions. Our flexible cloud-based software solution supports you with HIPAA, OSHA, human resources compliance, and fraud waste and abuse laws.

Healthcare institutions must comply with an increasingly complex and changing set of laws and regulations. Violation of these regulations can endanger patient safety, violate patient privacy, and lead to strict legal and financial penalties. In light of the increase in government audits and investigations, it is critical that organizations establish processes, procedures, and policies as part of an effective healthcare compliance program.

Health care compliance is the process of ensuring that health care providers and businesses in related fields, such as insurance, follow the rules that apply to them. Healthcare compliance professionals develop and maintain compliance plans and oversee compliance with key rules and regulations. In this way, compliance officers have an essential role in maintaining an effective and safe environment for patients and staff. The primary focus of any healthcare organization should be to foster a culture of compliance, including the implementation of an effective health care compliance program. This enables them to find and correct potential vulnerabilities, reduce the likelihood of fraud and abuse, and promote safe, high-quality care.

To achieve such a level of compliance, healthcare providers and organizations must use the seven core elements as a foundation. These elements can serve as general guidelines for creating a compliance culture and proactively addressing any compliance deficiencies. Each organization and healthcare provider must identify all laws and regulations that apply to their specific organization. Federal laws applicable to health care are comprehensive and are implemented by multiple federal agencies. As discussed above, HHS is responsible for Medicare, Medicaid and the other federal health care programs, as well as HIPAA privacy and security rules. Most health care organizations and providers are also subject to the regulatory framework of the Food and Drug Administration, the DEA, and many other state and federal agencies.

Healthcare compliance also helps healthcare organizations and caregivers avoid problems with government agencies. An effective health care compliance program can identify problems and find solutions to those problems before a government agency finds the problem. An effective health care compliance program can also reduce the imposition of financial penalties or fines that might otherwise be imposed on the healthcare organization what is healthcare compliance or provider. A review of recent OCR settlements for HIPAA violations shows that OCR imposes higher fines when the health care organization has failed to develop and implement effective HIPAA compliance. Because of the volume and complexity of this regulatory framework, most healthcare organizations and providers must rely on healthcare compliance specialists to develop, implement, and update their compliance programs.

One of the first forms of health care compliance was the establishment of minimum standards for surgical facilities by the American College of Surgeons in 1918. Today, the amount of regulation that applies to healthcare organizations and health care providers requires them to have dedicated team members specifically focused on health care compliance. Healthcare organizations cannot reap the benefits of their compliance programs unless they use them.

Effective healthcare compliance should be a continuous process of continuous review and updating of the organization’s processes, policies, and procedures. The organization must also constantly update the training given to its employees based on regulatory changes. Each year, CMS conducts extensive error rate testing to determine how health care providers are doing regarding billing, coding and documenting services provided to Medicare beneficiaries. CMS analyzes healthcare providers, hospital services, and durable medical devices to assess a sample of claims and documentation in the United States. This example of claims and documentation helps CMS see the bigger picture of how all healthcare providers bill, code, and document services provided.

An HCO must also conduct regular audits to ensure that state and federal standards continue to be met. This is especially important to help healthcare institutions stay up-to-date as laws and regulations change. HCOs use their knowledge, preparation and leadership skills to implement change within the organizations where they work. A well-organized healthcare compliance officer can not only help the facility maintain compliance and reduce fines and penalties, but also increase communication, trust, and most importantly, patient safety. Policies, procedures, and standards of conduct should promote healthcare organizations’ commitment to compliance and address specific risk areas. In addition, according to the OIG, this element of a health care compliance program should help employees perform their duties in a way that ensures compliance with the requirements of the federal health care program.