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The Effective Healthcare Compliance Program for You

The Effective Healthcare Compliance Program for You | Heath Hyde

Table of Contents

What does an Effective Healthcare Compliance Program entail?

Why is it necessary for every health-care organization to have a strong healthcare compliance program?

A healthcare compliance program shows employees and the public that the company is committed to honesty, ethics, and responsible behavior. It encourages employees to report issues and establishes a system for the company to detect and prevent criminal and unethical behavior. It can also assist in identifying and correcting compliance issues before they are discovered by the government or revealed by a whistleblower, such as Anti-Kickback Statute and Stark Law infractions.

More importantly, if health care fraud is discovered within your health care company without an adequate compliance policy in place, your culpability may be elevated. This can lead to accusations of willful ignorance, as well as follow-up inquiries. Our health care compliance consulting attorneys at Heath Hyde can assist your firm on how to comply with state and federal healthcare rules and best practices.

What Does a Good Healthcare Compliance Program Look Like?

An effective healthcare compliance program is a proactive measure. It can reduce fines and penalties resulting from health care fraud investigations and prosecutions, by reducing the organization’s culpability score. The U.S. Sentencing Guidelines provide for reduced criminal fines and penalties for organizations, including health care organizations, that have implemented a healthcare compliance program prior to the offense. The Office of the Inspector General (OIG), for example, will consider the existence of an effective healthcare compliance program that pre-dated any governmental investigation when addressing the appropriateness of administrative penalties.

Further, the False Claims Act provides that a person who has violated the FCA, but who voluntarily discloses the violation to the government, in certain circumstances will be subject to double, as opposed to treble, damages (see 31 USC 3729(a)).

Moreover, an effective healthcare compliance program actually prevents investigations and qui tam cases in the first place. By identifying and correcting improper payments, responding to a hotline and other complaints, and monitoring and self-auditing compliance with program requirements, an organization may prevent an investigation from ever happening.

The government also takes into account whether a health care provider has an effective compliance program in place when deciding to prosecute or impose penalties (USAM 9-28.800).

Monitoring and auditing under a healthcare compliance program are essential to complying with federal overpayment or “reverse false claims” requirements, and to identify and self-report any violations of law or CMPs before an investigation begins. By returning overpayments on a timely basis and self-reporting violations, an organization can significantly reduce CMPs and other penalties.

An Effective Compliance Program Must Include All Seven Elements Found in the Federal Sentencing Guidelines:

  • Written policies and standards of conduct.
  • Compliance officer and compliance committee.
  • Effective training and education.
  • Effective lines of communication and hotlines.
  • Enforcement through disciplinary actions.
  • Monitoring and auditing.
  • Prompt response and corrective action.

The HHS-OIG has published Healthcare Compliance Program Guidance for a number of health care industries, including hospitals, physicians, nursing facilities, hospices, home health agencies, clinical laboratories, durable medical equipment suppliers, and Medicare Advantage organizations.

The HHS-OIG guidance should be carefully reviewed and used in developing a compliance program. If no guidance exists for your industry type, consult the guidelines for similar provider types.

Get a Professional Help from Heath Hyde

Let Our National Healthcare Lawyers at Heath Hyde Help Develop an Effective Compliance Healthcare Program for Your Practice – You will sleep better at night.

The health care compliance attorneys at Heath Hyde Law have 35 years’ experience in state and federal health care regulations and best practices across the U.S. 

Our lawyers analyze policies and procedures, to ensure that licensed healthcare providers avoid criminal and civil liabilities for False Claims Act, Anti-Kickback and Stark Law violations — and we defend providers who face related charges.

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