Author: Peyman Zand, Partner, Strategic Services Executive – CFCHE
Developing a comprehensive compliance program is no longer optional for healthcare providers. Successful Compliance programs provide protections for provider entities, and patients alike. There is no single “best compliance” program. Providers with limited resources must still develop and maintain an active compliance program. Larger organizations may have entire departments dedicated to maintaining compliance standards. Healthcare providers compliance programs should be customized to each entity, based on the identifiable areas of risk. The OIG adoption of the underlying principles to provide a baseline of compliance structure that can be adjusted to the specific needs of the organization. At a minimum compliance programs should:
- Establish clear internal guidelines in the form of published policies and procedures relative to billing, staff behavior, and patient protections.
- Provide an atmosphere in which employees are free to report potential compliance issues in an unfettered risk free environment.
- Identify a Compliance Officer who maintains overall responsibility for the entities compliance and reporting processes.
- Establish strict management and control over protected patient health and financial records.
- Ensure technologies are in place to monitor compliance efforts and programs with the organization.
Creating Compliance Programs
Compliance programs impact the entire spectrum of a facilities financial and clinical operations. As such it is important to develop an appropriate structure of policies and people to administrate, provide advice and ensure adherence to published compliance regulations. Creating a compliance structure will not eliminate Audits, but can provide additional levels of protection for the providing facility. Identifying the correct staff to implement the compliance program is the first of several steps. Developing a compliance structure includes adherence to CMS billing standards, coding accuracy, and accurate translation of health records to the Revenue Cycle solution.
Maintaining a Compliance Program
As regulations change, facilities must adapt and evolve their internal governance processes. Billing regulations change frequently requiring providers to stay on top of the latest software revisions, as well as monitoring the changing “code sets” that enhance the billing process. A good compliance program will include a clearly defined process of systems maintenance and staff re training. Staying current on the latest compliance trends is an integral part of any compliance program.
Compliance Audits
Compliance audits are among provider’s most stressful activities. As such providers must have a clearly defined audit process. The process must include timely provision of requested patient records/charts that are fully completed, uniform in presentation, and clearly and consistently labeled. Having a solid compliance program in place and in practice will prepare a client well for any audit activity.
