Developing and implementing an effective compliance program is critical for all healthcare organizations. A successful compliance program addresses the public and private sectors’ mutual goals of reducing fraud and abuse; enhancing healthcare providers’ operations; improving the quality of healthcare services; and reducing the overall cost of healthcare services. Attaining these goals benefits the hospital industry, the government, and patients alike. Compliance programs help hospitals fulfill their legal duty to refrain from submitting false or inaccurate claims or cost information to the federal healthcare programs or engaging in other illegal practices.
Measuring Compliance Program Effectiveness: A Resource Guide, released by the Office of Inspector General (OIG), assists organizations with their compliance efforts.
This guide was developed by the Department of Health and Human Services, Office of Inspector General in collaboration with a group of healthcare compliance professional through a joint effort with HCCA. The resource guide is a compilation of ideas for measuring various elements of a compliance program. The guide addresses the following elements of a compliance program:
- Standards, Policies, and Procedures
- Compliance Program Administration
- Screening and Evaluation of Employees, Physicians, Vendors and other Agents
- Communication, Education, and Training on Compliance Issues
- Monitoring, Auditing, and Internal Reporting Systems
- Discipline for Non‐Compliance
- Investigations and Remedial Measures
The OIG strongly encourages hospitals to identify and focus their compliance efforts on those areas of potential concern or risk that are most relevant to their individual organizations. The value of any metric is dependent on an organization’s individual needs. The frequency of use of any measurement should be based on the organization’s risk areas, size, resources, industry segment etc. Each organization’s compliance program and effectiveness measurement process will be different.
The intent of this guide is to provide organizations with as many ideas as possible so that any type of organization can choose those metrics that best suit its needs. OIG is clear that this is not intended to be a “checklist” and trying to use all of the metrics listed is impractical and not recommended.
Of special note, CMS recently released new regulations for Long Term Care facilities. Conditions of Participation 483.85 (implementation date of November 28, 2019) addresses a compliance and ethics program. CMS defines a compliance and ethics program, with respect to a LTC facility, as a program of the operating organization that; has been reasonably designed, implemented, and enforced so that it is likely to be effective in preventing and detecting criminal, civil, and administrative violations under the Act and in promoting quality of care; and includes, at a minimum, the required components as follows:
- Established written compliance and ethics standards, policies and procedures to follow
- Assignment of specific individuals with the overall responsibility to oversee compliance with the organization’s compliance and ethics program’s standards, policies, and procedures
- Sufficient resources and authority to the specific individuals designated as above to reasonably assure compliance with such standards, policies, and procedures.
- Due care not to delegate substantial discretionary authority to individuals who the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in criminal, civil, and administrative violations under the Social Security Act.
- Effective communication of the compliance and ethics program to staff, contracted staff providing services, volunteers (includes mandatory training)
- Taking reasonable steps to achieve compliance with the program’s standards, policies, and procedures
- Consistent enforcement of standards, policies, and procedures through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect and report a violation to the compliance and ethics program contact (compliance officer).
- After a violation is detected, the organization must ensure that all reasonable steps identified in its program are taken to respond appropriately to the violation and to prevent further similar violations, including any necessary modification to the operating organization’s program to prevent and detect criminal, civil, and administrative violations under the Act.
Healthcare organizations must review their compliance program and revise as needed to reflect changes in all applicable laws or regulations and within the operating organization and its facilities to improve performance in deterring, reducing, and detecting violations under the Act and in promoting quality of care. The Measuring Compliance Program Effectiveness: A Resource Guide, is an excellent tool for healthcare organizations to use when reviewing their compliance program.
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