Healthcare compliance programs affect all types of health care practitioners and organizations. While some view healthcare compliance as an inappropriate intrusion by the government and the imposition of unnecessary oversight on medical practitioners who devote their lives to caring for the sick, others view it as a means of improving the availability, cost, and quality of healthcare. An understanding of health care compliance programs is a starting point for those practitioners who are ignorant about its objectives.
What is Healthcare Compliance?
Healthcare compliance involves meeting the ethical, professional, and legal standards required for a particular health provider or organization. Healthcare compliance means that medical practitioners and facilities should develop effective policies, procedures, and processes that stipulate the appropriate conduct, train the facility’s staff, and monitor the adherence to these measures. Healthcare compliance covers areas such as billing, patient care, HIPAA privacy, and reimbursement. An attorney can help you formulate a compliance program that includes the most important elements that affect your specific practice.
Each government agency involved with regulating healthcare deals with the specific area it controls. For example, the Drug Enforcement Administration (DEA) enforces laws associated with controlled substances. The DEA’s healthcare compliance focuses on managing the use of controlled substances.
The Department of Health and Human Services (HHS) Office of the Inspector General (OIG) focuses on protecting healthcare programs from abuse, waste, and fraud. According to the OIG, a healthcare compliance program should cover seven areas. This compliance guidance by OIG is centered on eliminating abuse, fraud, and waste. The sevenareas recommended by OIG are:
- The development and implementation of written policies, procedures and standards of conduct that describe a particular organization’s commitment to addressing and exceeding the ethical and legal standards affecting its practice.
- Assigning a chief compliance officer, committee, and individuals charged with monitoring and operating the compliance program and reporting directly to the chief executive officer of the organization.
- Developing an education and training program for employees
- Developing and maintaining an effective line of communication for allowing people to report concerns with the compliance program and make anonymous complaints
- Developing and implementing a procedure for responding to complaints and concerns including taking corrective measures like disciplinary actions against employees
- Using internal audits and monitoring to address deficiencies and measure compliance
- Responding quickly and appropriately to offenses
A healthcare compliance program should also satisfy other regulatory compliance elements applicable to the provider or medical organization in question. Since every health provider and organization deals with patient information, they need to include the Health Insurance Portability and Accountability Act in their compliance program. The HHS Office of Civil Rights is involved with the implementation of HIPAA security and privacy rules and provides guidance on complying with these rules.
Where are the Requirements for Healthcare Compliance?
Every healthcare provider and organization can identify the rules and regulations applicable to their specific practice through the guidance of an attorney. The federal laws dealing with healthcare are complex and are monitored by different federal agencies. For example, HHS deals with Medicaid, Medicare, HIPAA, and other healthcare programs. Many healthcare providers and organizations are subject to the Food and Drug Administration, Drug Enforcement Agency, and other federal and state agencies. Each government agency issues regulations and rules that stipulate the laws that they are responsible for implementing.
Importance of Healthcare Compliance
The main motive of healthcare compliance is improving patient care. When healthcare decisions are premised upon current and appropriate clinical standards, patient care improves. Healthcare compliance also helps providers and organizations avoid the bad books of government agencies. An effective healthcare compliance program identifies problems and implements solutions to issues before the intervention of government authorities. A good health care compliance program also mitigates financial penalties, and imposition of sanctions that are likely to be imposed on a healthcare provider or organization.
A review of the cases involving HIPAA breaches shows that OCR imposes steep fines when a healthcare provider or organization has not develop an effective HIPAA compliance. An effective compliance program also helps healthcare providers and organizations avoid being prosecuted for malpractice. Healthcare providers or organizations should document that they are abiding by current medical standards. A healthcare provider or organization who is following the best clinical standards is less likely to be accused of malpractice.
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