While there is no “off-the-shelf” solution for meeting the Office of Inspector General’s (OIG) expectation that all health care organizations will have an “effective” compliance program, guidance exists for key elements that will be taken into account if your organization is ever accused of fraud or abuse.
Basic expectations for health care compliance programs were first outlined in the Federal Sentencing Guidelines in 1991, and later updated in 2004. The intent of the sentencing guidelines was to ensure consistency in sentencing and promote good corporate citizenship by creating incentives for organizations to self-initiate crime prevention efforts. The guidelines set forth seven basic elements and have become the de facto standard for compliance programs. These elements are not only taken into account in terms of sentencing, but also form the framework for most Corporate Integrity Agreements (CIAs) that allow organizations to settle claims and avoid exclusion from Medicare and Medicaid programs.
If you’re not already familiar with the following seven elements, it will behoove you to do so. And even if you’re familiar with them, it may be helpful to consider where you stand on achieving “effectiveness” in each of these areas across all of your service lines:
- Implementing written policies, procedures and standards of conduct
- Designating a compliance officer and compliance committee
- Conducting effective training and education
- Developing effective lines of communication
- Conducting internal monitoring and auditing
- Enforcing standards through well-publicized disciplinary guidelines
- Responding promptly to detected offenses and undertaking corrective action
TCG’s Compliance QuickTips© series addresses each of these elements in greater detail and provides tips on how you can move beyond the bare minimum to establish a robust program of ethics and compliance for your organization.