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Riddle Compliance
Riddle Compliance

Developing a Comprehensive Healthcare Compliance Program for Long-term Success

It might feel tasking to comply with the numerous federal laws that dictate how healthcare services should run. However, having a robust compliance program in place will work in your favor. 

Most compliance programs exist to ensure that providers follow government regulations without reducing the quality of care given to patients. It prevents any criminal practices from thriving in your organization and creates an overall risk-free environment.

Once you establish a solid program, it’ll stop being overwhelming and give you relief that your practice is being run in accordance with the law.

The Latest OIG Compliance Program

Once voluntary guidelines provided by the OIG were made mandatory. The guidelines were to help providers have an effective compliance program at their respective practices. The OIG presented them in the form of seven elements that should constitute the basis of all compliance systems.

  • Adopt and implement written compliance regulations. Healthcare practices must write policies to guide their compliance efforts. These procedures should then act as a reference for all practitioners in the practice. It’s best if you schedule reviews periodically to keep everything up to date.

  • Appoint a compliance officer. Your practice should pick an individual to monitor compliance by ensuring that everyone is making efforts towards complying with the policies set in place. A compliance consultant can help you decide where your compliance officer will lie in the organization’s structure and who they’ll report to if issues arise.

  • Conduct internal audits. Your practice should carry out regular audits of the policies to ensure that the compliance team identifies any violations and deals with them before they get out of hand. As a bonus, you can decide to review previous compliance violations and gauge whether the corrective actions you put in place are working.

  • Regularly train employees. Recruits should undergo training on all compliance issues including but not limited to fraud, reporting, waste, and the False Claims Act. Current employees should also get refresher courses on the same, and all sessions should be under record.

  • Establish disciplinary measures. For compliance to become an important part of any organization, there must be repercussions for individuals who don’t comply with the policies. The repercussions should be the same across the board, meaning senior members of the organization won’t have a reason not to comply.

  • Have safe reporting systems in place. Your practice should set up a system where employees can report any suspected compliance violations without fear of judgment. It could range from a confidential hotline or email system that encourages them to come forward. Also, ensure that they’re aware that these avenues exist and people are listening on the other side.

  • Have correct procedures in place. Your organization should have policies for corrective actions to be taken in case an audit reveals a violation. They should also cover how to respond to potential violations presented by employees so compliance officers can have quick reaction times.

The procedures shouldn’t only highlight how to respond to the issues at hand, but they should also emphasize the identification of the root causes to prevent a repetition of the same.

Recommendations from the Centers for Medicare and Medicaid Services

In the late ’90s, the CMS took over the Medicaid Alliance for Program Safeguards and created guidelines for managed care organizations that conduct business with state Medicaid agencies. 

While the CMS guidelines are more or less similar to the ones provided by the OIG they come with extra recommendations for organizations to implement. Here are some of the recommendations

1. Create a Compliance Organization and Documents to Show the Organization’s Commitment to Ethics & Compliance

The CMS recommends that you bring together a team to discuss all matters related to healthcare regulatory compliance. These are the people who will review the existing compliance program. 

The team should document the process through which they create a compliance plan for maximum efficiency. Your practice can do this using board minutes or a policy statement that you include at the start of your compliance plan. 

2. Establish Policies to Guide the Compliance Committee

Your practice should have a compliance officer and other individuals like senior officials form a compliance committee after the review team has done its work. The compliance program can have a section detailing how the committee should operate and all criteria that qualified them for their positions.

3. Identify Relevant Medicaid Managed Care Policies and Programs

Your practice needs to identify the correct regulations that the compliance team will monitor in the compliance plan. It should also highlight high-risk operational areas for more frequent review. 

Fortunately, the guidelines for a strong healthcare compliance program in Managed Care Organizations (MCOs) apply to most practices and are a great starting place for your organization.

After picking the regulations, your practice now can interpret and analyze how each one of them applies to your internal operational processes. You can achieve this by looking at which of your organizational functions fit under the hood of specific regulations.

From there, you can proceed to paraphrase them in a way that’s easy for your staff to understand. The CMS recommends that the resulting document contains:

  • A summary of the original regulations or citations and where you sourced them from

  • How your board of directors interpreted the regulations during the analysis

  • The organizational functions that are covered by each regulation

  • The organizational requirements for complying with the regulations

  • Where to find supporting policies

  • How to monitor the resulting standards that you set

The Importance of Healthcare Compliance 

People will identify the organization as an ethical practice that prides itself on maintaining professional standards once it complies with all standards set by the OIG compliance program.

Other patients and employees will gain trust in your entity since they’ll know you handle all compliance issues before they get out of hand and keep them under continuous monitoring to prevent a reoccurrence.

In addition to that, most health insurers require that providers have a compliance program before they establish any business relationship. Providers that don’t have a healthcare compliance program also violate the Affordable Care Act (ACA) and find themselves unable to involve themselves in any healthcare programs.

A strong compliance program will ensure it remains relevant over the years, and your organization will be free from various crimes and regulatory shortcomings. 

If your organization is concerned about governance, risk mitigation, regulatory compliance, healthcare compliance consulting, and ethics, we can simplify things for you. Contact us for more information. We’re passionate about supporting our clients with respect, transparency, and unparalleled expertise.