HCA Compliance Week 1 (Chapter 8)

Compliance officer Responsibilities

- relevant authorities for standards of condudct/legal risks - developing P&Ps for implementation of compliance procedures - delivery of education sessions - audit, monitoring, and assessment tools, and evaluation - investigation of all non-compliance - corrective action - regularly with board and serving as a member of any executive level compliance oversight committee

Evolution of compliance

1980 - detect and prosecute fraud/abuse 1990 - focus turned into fraud in Healthcare industry 1991 - Federal sentencing guidelines 1993 - attorney general janet reno made healthcare fraud a priority - began to publish voluntary compliance guidelines. - Clinic Lab Compliance 1998 - OIG compliance program for hospitals - prevention of fraud (voluntary) further mission of all hospitals 2005 - supplemental guidance for hospitals

What is a compliance Program?

A written Document designed to clearly express what laws effect the facility . Expected behaviors as a result of the law's directives and company policies related to these laws. The consequences that can be expected when violations occur. Plan to correct violations and implement mechanisms to prevent is future occurrence. written plan to monitor effectiveness.

Purpose of compliance programs

Many governmental agencies oversee the provision of Healthcare services. (federal & State) - administrative agencis: IRS, HHS, CMS Many laws and regulations. Difficult to clearly understand responsibilities and expectations Purpose of the compliance program is to interpret the laws properly. - provide each employee with an unmistakable understanding of proper behavior. - prevent fraud and abuse - improve healthcare quality - control expenses - limit liability - advance the organizations mission

Benefits of compliance program

Promotes organizational success - ignorance of the law is not a defence - anti kick back statues, fraudulent coding/billing, HIPAA Planned approach to educate staff of important rules and regulations promotes quality of care, and decreases liability. Establishes an evironment of honesty Improve service to patients Minimize loss Reduce liability Provides a mechanism to address issues timely.

Compliance officer

critical component to the success of the program should be a member of senior managment high integrity autonomy Healthcare complaince certifications

Compliance Committee

for larger facilities/hospitals. establish effective strats to detect and prevent fraud/abus Investigate alleged violations, including launching of hotline reporting, and protection of whistleblowers and other reporting systems Perform regular assessment of the industry Assessment of policies and procedures and update to reflect changes in the laws. Promote honesty and compliance support training and education.