In today’s world, healthcare is more complex than ever. That may be at least one reason why fraud has been increasing in this industry. The National Health Care Anti-Fraud Association (NHCAA) reports that financial losses due to fraud run in the tens of billions of dollars every year. The high rate of medical fraud is fomenting an increase in governmental inquiries, audits, and investigations. The U.S. HHS and the Department of Justice recovered over $4.3 billion in healthcare fraud and abuse in 2013 alone. The Office of Inspector General (OIG) of HHS has been the leading force behind battling waste, fraud, and abuse in over a hundred HHS programs, including Medicare and Medicaid, since its inception in 1976.
Rapid changes in healthcare forced everyone to place a greater emphasis on preventing and detecting violations of state and federal healthcare laws. A well-planned healthcare compliance program is a good defense against fraud and can aid in investigations if they should occur.
What Is the Purpose of a Compliance Program?
Many health insurers require or at least recommend that all medical providers establish a compliance program for their benefit and everyone else’s. Under the Affordable Care Act (ACA), physicians and group practices must establish compliance programs if they want to provide services under Medicare, Medicaid, and Children’s Health Insurance.
Many commercial insurers also require medical providers to have a healthcare compliance plan as a condition of participation in their programs. Providers that fail to establish a healthcare compliance plan have a strong risk of not being able to participate in any kind of healthcare program.
CMS states that medical providers will be able to better protect themselves from the risk of improper conduct if they have a good compliance program in place. A solid compliance program will promote the prevention of criminal behavior, ensure that government rules and regulations are being enforced, and provide quality care to patients. In addition, compliance programs help protect against fraud, improper payments, abuse of the system, and other liabilities.
The ACA Has Seven Core Elements for an Effective Compliance Program:
The ACA recommends that healthcare providers implement a compliance plan, if they haven’t yet, that includes the seven core elements as a foundation for their program.
- Establish and adopt written policies and procedures to promote the provider’s commitment to compliance. Include sanction screenings as part of the healthcare compliance plan. Ensure that there’s a routine process in place to monitor potential compliance issues.
- Identify and appoint an individual to serve as the compliance officer and charge this person with the responsibility for monitoring compliance efforts and enforcing practicing standards.
- Establish reporting systems whereby individuals can report complaints about compliance items without fear of retaliation. Some providers have found it to be helpful to set up an anonymous hotline number.
- Make a commitment to offering formal education and training programs at all levels of employment. Make it part of the employee orientation process.
- Continually audit and monitor systems to ensure that they’re effective and to head off potential problems.
- Develop policies to enforce the standards of conduct and establish disciplinary measures for employees who don’t comply with the requirements.
- Take corrective action when vulnerabilities are identified.
Beyond what the ACA recommendations for an effective compliance program, there are several other things that organizations can do to ensure compliance and help prevent fraud.
First, assemble a compliance committee that includes a cross-section of employees. The responsibility for compliance essentially belongs to everyone. A team approach can be an effective way to extend the approach to compliance beyond the designated compliance leader. This group should set up a group charter and could include case managers, IT, C-suite members, and other employee representatives. To be effective, the group would meet at least quarterly. All members of the group should be committed to maintaining confidentiality within the group.
Next, be sure to define and document conflicts of interest. Board members and members of the management team should be asked to sign a conflict of interest statement as part of the healthcare compliance plan and keep these documents on file.
Set up a chart review process to examine the use and application of codes and track for certain procedures or supplies.
Measure your compliance programs to ensure they’re effective and providing all the information that you need. Conduct an internal evaluation every year to assess how it’s working. Also, do an external audit every other year and get a report from it that details improvements to your program.
Finally, take some help from technology. BoardEffect offers all the features you need for managing board and committee meetings. Use the software to create board meeting agendas and meeting minutes and set up event schedules with automatic notifications. The program also streamlines the processes for meeting quarterly and annual cycles for meetings and reporting. Compliance committees would also have access to the online Resource Library to help inform their work. The Resource Library is also a great resource to help enhance orientation programs.
BoardEffect’s platform offers digital solutions to promote effective decision-making that leads to better outcomes for healthcare organizations with a modern approach to compliance and governance. BoardEffect is trusted by over 2,500 boards and 180,000 users.
To mention some of the other valuable features of a BoardEffect portal, users have the benefit of digital solutions for surveys and collaboration. The platform is highly secure and has secure, granular controls, as well as unlimited cloud-based storage. Users also have the advantage of having an intuitive mobile experience and access to documents 24/7.
Benefits of Comprehensive Compliance Program
There is much to gain from a comprehensive compliance program and virtually nothing to lose. The problems with healthcare have not yet reached a tipping point. The industry will continue to evolve in the coming years and new compliance regulations are likely to be forthcoming. An effective compliance program will help to minimize billing mistakes, lessen the chance of an audit, increase payments for claims reduce the chances of fraud and abuse, and promote safe and quality patient care.