The Seven Elements of an Effective Compliance Plan

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As a healthcare provider, do you have a compliance plan in place?  Healthcare providers and business associates are required by law to have a compliance program.  And as a part of the program, we are mandated to have a compliance plan.  Unfortunately, there is not a “one-size- fits-all” template that providers are able to adopt.  Each organization is different, with different operational environments and ways of doing things.  Due to this uniqueness, it makes sense that each compliance plan would differ from one to another.

While the process of creating a compliance program can be daunting, having one is advantageous.  First, it is a proactive way to ensure that you are meeting the statutory and regulatory requirements.  Second, it shows the government your good faith effort to comply with the law should you ever become the subject of an investigation.  Along with that, should you ever become convicted for violations of any of these statutes and/or regulations, having a compliance plan is favorably considered at sentencing.

Here are the seven fundamental elements of an effective compliance program:

Designating a compliance officer

The first thing to do is to designate a qualified individual to be your compliance officer.  It is highly recommended that larger organizations appoint at least one dedicated compliance officer, whose sole duties are to manage compliance-related tasks.  We greatly suggest that the compliance officer is certified and stays up-to-date with federal and state regulations.

Implementing written policies, procedures, and standards of conduct.

Next, create standards that effectively convey to your staff and third parties, such as vendor partners, your goals and expectations with regards to the way you want to conduct business.  The goal is to inform your staff of their duties and responsibilities that correlates to proper billing functions and staying within the confines of governmental regulations.  Your standards may differ from another entity’s, but it should include a code of conduct, mission statement, and policies and procedures that demonstrate your commitment and effort to adhere to healthcare regulations.

Conducting effective training and education

Possessing proper policies and procedures is only part of the equation, it is essential that you also have a comprehensive on-going training programing.  Your employees need to know their job responsibilities as well as healthcare regulations, such as HIPAA, Anti-kickback Statute, Stark Law, OSHA, etc.  While training methods may vary, all training sessions should be documented and provide proof that your employees received the training.

Developing effective lines of communication

Once your staff has been sufficiently trained, they need to know that they have the responsibility to report any problems that they encounter within their line of duty so that they can be properly addressed and corrected.  Your employees, patients (or family member to the patient) should feel comfortable to report a complaint without any adverse consequences or retribution.

Physician Revenue Navigators has an open-door policy.  In addition, we partner with ComplianceHotline to offer multiple mechanisms for reporting (online, email, telephone, fax, and mail).

Conducting internal monitoring and auditing

Auditing is a significant element.  A gap analysis (baseline audit) should be initially performed to identify risk areas or areas that need improvement before the ongoing audits.  Audits should be performed at both scheduled intervals (yearly, quarterly, etc.) and when a problem has been identified.

Enforcing standards through well-publicized disciplinary guidelines

Your compliance program needs written guidelines that clearly identifies prohibited conduct and the penalties in engaging in such conduct.  Your employees must understand that they will be held accountable for improper behavior.  The scale of discipline should be progressive, from verbal warning to written warning to termination of employment, depending on the number or severity of the conduct.

Responding promptly to detected offenses and undertaking corrective action

Once problems are detected, they must be addressed, investigated, and corrected as quickly as possible.  The government frowns on indifference (i.e. not taking action) when you know that there is a problem.

Screening and evaluation of employees, physicians, vendors and other agents

In addition to the seven elements, providers and business associates are also mandated to routinely screen for excluded individuals from federal and state healthcare programs.  Exclusion Screening, LLC. is our partner who regularly conducts the required screenings for us.  Exclusions can result from misconducts such as medical malpractice, patient abuse or neglect, fraud, regulatory violations, sale or abuse of drugs, etc.  It is important to note that any claim that is associated to an excluded individual becomes an overpayment to the provider.  We are now seeing this screening requirement in insurance carrier contracts.  Employing an excluded individual can result in civil monetary penalties and in some cases, violation of the False Claims Act.

Physician Revenue Navigators is a premier company that provides revenue management for healthcare entities. Contact us to learn more about how we can help you stay in compliance with regulations.

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