In 2013, the Department of Health and Human Services recovered $4.5 million from individuals and firms that committed health care fraud. The agency accomplished this success because of health care fraud regulations requiring care providers to implement compliance and ethics controls. The regulations require health care organizations to develop programs that actively promote ethical culture and reinforce compliance commitment. By promoting moral behavior with internal and external influences, compliance officers guide staff members in making moral decisions and conforming to the law.
The United States government has opposed fraudulent claims since the Civil War, resulting in President Lincoln endorsing the first antifraud law, called the Fraudulent Claims Act, in 1863. Today, the Affordable Care Act (ACA) includes several provisions designed to reduce health care fraud and improve patient outcomes. The framework of the provisions originates from U.S. Federal Sentencing Commission Guidelines, and incorporates the following practices.
Policy, Procedure and Standards of Conduct Implementation
Documented policies and procedures support organizational uniformity. Accordingly, health care compliance officers publish clearly written policies and expectations to reinforce conduct standards.
Larger organizations form compliance committees that work together to develop policies. The compliance committee presents new regulations to all employees and ensures new employees review policies within 90 days from their start date. Additionally, all employees sign documentation that acknowledges their review and understanding of the organizational policies.
Compliance and Ethics Officer and Committee Election
Ongoing training ensures that staff members remain aware of current organizational policies and standards. This includes teaching general compliance guidelines to all staff members, supervisors and managers. Additionally, all new employees must undergo training before or beginning their first day of work. Compliance officers also host annual training sessions to review policy changes and developments. The annual sessions help to reinforce organizational policies for all staff members.
Maintaining Organizational Communication
Employees must feel that supervisors and managers will receive their concerns with neutrality. Two-way communication facilitates compliance. To support this environment, compliance personnel implement procedures for voicing concerns. The procedures allow employees to report issues anonymously if desired. While larger enterprises may provide a toll-free hotline for this purpose, smaller firms might implement an open-door policy.
Ongoing Monitoring and Auditing
Effective health care organizations routinely monitor and audit compliance performance. These processes ensure that organizations comply with regulations and uncover compliance risks.
Monitoring involves ongoing evaluation as a part of daily operations, while audits involve an annual, semi-annual, or quarterly process where compliance officers benchmark staff member performance against organizational standards. Both processes may produce results that, when necessary, organizational leaders use to take corrective action.
Disciplinary Standards Enforcement
When a compliance offense requires disciplinary action, organizations follow standardized procedures. Written policies outline exactly what actions an organization takes when offenses occur. The outline includes provisions for noncompliance, failure to detect noncompliance due to negligence and failure to report noncompliance. When these incidents occur, managers levy outlined punitive actions quickly and, while protecting the offender’s privacy, issue written or verbal statements detailing the offense to discourage other staff members from repeating the act.
Corrective Action and Offense Response
When risk monitoring, audits or risk assessments uncover violations, compliance officers pursue corrective action that corresponds with the violations. Corrective action might include recovering overpayments and penalizing offending employees.
Preferably, the subsequent penalty provides relief that makes the individual or enterprise “whole,” meaning the injured party is returned to a condition as if the event never happened. Compliance officers record the relief plans and ensuing actions that will ensure the infraction does not recur.
Maintaining Compliance to Promote Positive Outcomes
The Affordable Care Act holds organizational boards of directors responsible for upholding compliance in daily practice. The Federal Office of the Inspector General (OIG) oversees compliance and has promised to diligently enforce remedies. However, health care organizations practice compliance, ethics and quality control to fulfill the primary goal of producing positive patient outcomes. Rather than viewing compliance as a burden, it is important that leaders view the practice as an opportunity to improve service performance and organizational safety.
Health care compliance officers develop and manage organizational policies. They possess expert knowledge regarding compliance risks and management. Consequently, health care organizations rely on compliance officers not only to ensure legal conformity, but also to promote the best possible outcomes for patients.
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