Developing an Effective Compliance Program

ORLANDO, Fla. - Does your practice or department have an effective compliance program? It should, because it’s the law and the federal and state officials have stepped up enforcement, said Jeff Hayes, MS, CHC, of Healthcare Compliance Specialists PC, in Phoenix, Ariz.

“It is now absolutely mandatory that you have a compliance program,” Hayes said, speaking at a session at the 2012 annual meeting of AHRA, the association for medical imaging management. The Affordable Care Act, the latest regulation to include compliance, requires providers to have a compliance program as a condition for enrollment in Medicare or Medicaid. And that means commercial payers will likely also require it, he added.

Requirements for compliance programs date back nearly a decade, but what’s new is the level of enforcement, Hayes said. The Obama Administration has made health care fraud a priority. Prosecutions are up in recent years, and providers face tougher fines and penalties.

A compliance program is designed to prevent and detect criminal conduct, and must also promote a culture of ethical conduct and a commitment to compliance of the law, Hayes explained. Although the specific details for what the policy should look like under the ACA is forthcoming, the industry knows enough to set up an effective program now.

Hayes outlined seven essential elements of an effective compliance program:

• The program should include standards and procedures to be followed by employees to prevent and detect criminal conduct.
• The governing authority (like a board of trustees or practice owner) must be knowledgeable of the content of the program and must exercise oversight and assign responsibility to specific high-level individual in the organization (like a compliance officer or the administrator).
• The program must ensure no one in the organization has engaged in illegal activity.
• The program standards and policies must be effectively communicated to all work force members to create a culture of compliance.
• Set up monitoring and auditing systems, such as a direct phone line to a compliance officer or link on the site to send an email.
• There must be consistent promotion and enforcement of these standards, and adequate discipline for individuals responsible for an offense.
• Upon detection of criminal conduct, there must be the appropriate response, and the policy must include what efforts you are taking to prevent similar conduct.

So how do you develop such a program? Hayes recommended groups create a compliance professional within the organization, or hire a consultant or legal counsel. Software programs and training courses are also available to help, he said.

“You have to do it,” Hayes told attendees. “It’s part of the law.”