Compliance 201 for Health Care Providers
The Department of Health and Human Services (HHS) administers Federal funds intended to provide critical services to American Indian and Alaska Native (AI/AN) communities. These funds go to programs in Indian Country including the Head Start and Low Income Home Energy Assistance programs, as well as programs operated by Indian Health Service.
Unfortunately, vulnerabilities in the integrity of these programs can divert program funds intended to improve the health and well-being of AI/AN communities, disrupt the services these programs offer, and leave them open to fraud and abuse. To reduce these vulnerabilities, organizations can create compliance programs.
Compliance is the term used to describe an organization’s responsibility to conform its activities to internal policies and procedures and applicable laws and regulations, including Federal requirements. Compliance is important for many reasons, but most importantly, it ensures funds are used appropriately to provide quality services to your community.
This course gives an overview of the fundamental elements of a compliance program to help ensure your organization—as a health care provider—adheres to applicable statutes, regulations, and program requirements. The information in this course does not reflect mandatory components of a compliance program, but instead includes concepts, ideas, and suggestions for health care providers to consider as beneficial compliance practices addressing relevant risk areas.
For health care providers with existing compliance programs, this training may serve as a roadmap for updating or refining their compliance plans. For providers with emerging compliance programs, this training may facilitate discussions among facility leadership about including specific compliance components and risk areas. Also, consider taking our Compliance 101 training.
Course Objectives
At the end of this course, you will be able to:
- explain the purpose and benefits of a compliance program,
- identify the Seven Fundamentals of compliance,
- understand common compliance risk areas, and
- describe what you can do should you find a compliance error.
Resources to Help You
In this course, you will find a job aid and helpful resources. If you miss a resource as you go through the training, you can find them all in the last section of the course.
What is Compliance and Why is it Important?
What is Compliance?
Compliance is the term used to describe an organization’s responsibility to conform its activities to internal policies and procedures and applicable laws and regulations, including Federal requirements. Compliance is important for many reasons, but most importantly, it ensures funds are used appropriately to provide quality services to your community.
Organizations often create or have a compliance program through which they implement compliance plans and institute internal controls to ensure they comply with applicable rules. While the fundamental elements of a compliance program are generally the same, the specific components of a compliance program depend on the organization’s size and needs.
Why is Compliance Important?
Compliance is important for many reasons, but most importantly, it ensures funds are used to provide quality services to your community. It does this in a several ways. Click on each of the five flip cards below to learn the benefits of compliance.
Compliance helps you better understand whom your program serves, how program services are used, and helps you identify opportunities to strengthen program services.
Compliance helps you protect your scarce program dollars from fraud, waste, and abuse to ensure your funds most efficiently support your community.
Compliance helps you avoid mistakes and practices that may lead to audit findings, disallowances, and other investigations.
Compliance allows any organization to be proactive rather than reactive. It is a way for you to identify and address issues within your organization on your own and to take appropriate action.
Compliance ensures that your organization is providing high-quality services, using limited resources efficiently, and being a good steward of Federal funds
Benefits of Compliance Programs
OIG recognizes that most health care providers strive daily to provide high-quality, compassionate, cost-effective care to patients. A successful compliance program addresses the public and private sectors’ common goals of reducing fraud and abuse, enhancing the operations of health care providers, improving the quality of health care services, and reducing their overall cost. Meeting these goals benefits the health care industry, the Government, and patients. Compliance programs help health care facilities fulfill their legal duty by:
- providing quality care;
- refraining from submitting false or inaccurate claims or cost information to Federal health care programs;
- avoiding engaging in other illegal practices;
- increasing the likelihood of preventing unlawful and unethical behavior or identifying and correcting such behavior at an early stage;
- encouraging employees and others to report potential problems, which permits appropriate internal inquiry and corrective action and reduces the risk of False Claims Act lawsuits, and administrative sanctions (e.g., penalties and exclusion), as well as actions by States;
- minimizing potential financial loss to the Government and taxpayers, as well as corresponding financial loss to the health care facility; and
- enhancing patient satisfaction and safety through the delivery of improved quality of care.
While improper, unethical, or inefficient practices may not be entirely eliminated from a health care organization’s operation, the implementation of an effective compliance program serves to mitigate risks and minimize vulnerabilities. An effective compliance program demonstrates a health care facility’s good faith effort to comply with applicable statutes, regulations, and other Federal health care program requirements, and may significantly reduce the risk of unlawful or inefficient practices.
Tailor Your Compliance Program
Given the diversity of the health care industry, there is no single ‘‘best’’ health care facility compliance program. OIG recognizes the complexities of the health care industry and the differences among health care providers. Some health care facilities are small and may have limited resources to devote to compliance measures; others are affiliated with well-established, large, multi-facility organizations with a widely dispersed work force and significant resources to devote to compliance.
Accordingly, OIG does not intend this training to be ‘‘one-size-fits-all’’ guidance. OIG strongly encourages health care facilities to identify and focus their compliance efforts on those areas of potential concern or risk that are most relevant to their organizations. A health care facility should tailor its compliance measures to address identified risk areas and to fit the unique environment of the facility (including its structure, operations, resources, the needs of its population, and prior enforcement experience). In short, OIG recommends that each health care facility adapt the objectives and principles underlying this training to its own particular circumstances.
The 7 Fundamental Elements of a Compliance Program
While no single factor is conclusive of an effective compliance program, the following seven elements form a useful starting point for developing and maintaining an effective compliance program. The job aid, Guide to the Seven Fundamentals—in downloadable format below—includes more information on each fundamental and questions to ask yourself as you build or improve your compliance program.
Expand each section for a detailed review of the content.
The purpose of compliance policies and procedures is to establish rules that help employees carry out their job functions in a manner that ensures compliance with Federal health care program requirements and furthers the mission and objective of the facility itself. Typically, policies and procedures are written to address identified risk areas for the organization.
The Compliance Officer and Committee are the backbone of the facility’s compliance program.
A Compliance Officer should be knowledgeable and experienced in compliance and be empowered to run the program. The Compliance Officer should be a member of senior management and should report directly to the person at the top of the managerial hierarchy so that their issues are heard. The Compliance Officer may have to make some difficult recommendations, so they need to be at a level where other senior managers are colleagues and respect these recommendations. They should not be subordinate to the lawyers or the finance staff and should not have any responsibilities that involve acting in any capacity as legal counsel or supervising legal counsel functions.
The Compliance Committee should be comprised of top leadership and management representatives from across the organization and be led by a well-qualified Compliance Officer. The Compliance Committee’s responsibility is to implement the facility’s compliance program and to ensure that it complies with all applicable Federal health care program requirements.
Employee training and education are key parts of an effective compliance program. The purpose of having a training and education program is to ensure that each employee, contractor, or any other individual that functions on behalf of the facility is fully capable of executing their role in compliance with rules, regulations, and other standards.
Open communication is essential to maintaining an effective compliance program. The purpose of developing open communication is to increase the facility’s ability to identify and respond to compliance problems. Generally, open communication is a product of organizational culture and internal mechanisms for reporting instances of potential fraud and abuse.
Effective lines of communication can include tools such as routine compliance reports. Such reports can, among other things, demonstrate a commitment to quality of care and foster an organization-wide culture that values compliance.
By enforcing standards, or codes of conduct, health care facilities help create an organizational culture that emphasizes ethical behavior. OIG commends health care facilities that have adopted a code of conduct that details the fundamental principles, values, and framework for action within the organization, and that articulates the organization’s commitment to compliance. OIG encourages those facilities that have not yet adopted codes of conduct to do so.
Effective auditing and monitoring plans will help health care facilities avoid the submission of incorrect claims to Federal health care program payors. Health care facilities should develop detailed annual audit plans designed to minimize the risks associated with improper claims and billing practices.
By consistently responding to detected deficiencies, health care facilities can develop effective corrective action plans and prevent further losses to Federal health care programs.
If you identify a compliance error, you can take certain steps such as conducting an internal audit, changing policies to prevent the error moving forward, and educating employees. If the compliance error rises to the level of fraud, you can self-report to OIG here or call 1-800-HHS-TIPS.
Below is the job aid, Guide to the Seven Fundamentals. For each element, you’ll find questions to consider as you advance your program. The suggestions are not mandatory but are instead suggestions for health care organizations to consider as they develop beneficial compliance practices or assess relevant risk areas.
Course Summary
In today’s complex health care regulatory environment and increasingly large expenditures for health care, it is imperative for health care facilities to establish and maintain an effective compliance program. These programs should foster a culture of compliance and a commitment to delivery of quality health care that begins at the highest levels and extends throughout the organization. We hope this training has served as a resource for health care facilities to help them operate effective compliance programs that decrease errors, fraud, and abuse and increase quality of care and compliance with Federal health care program requirements for the benefit of the health care facilities and their patients.
Resources to Help You
The document below, Compliance 201 for Health Care Provider Resources, contains links to additional compliance resources such as our Tips for Implementing an Effective Compliance Program video. These resources may be helpful as you build or improve your compliance program.
Additional Trainings
After you complete this training, consider taking our additional compliance related trainings that can be found on our website. Below are three courses in which you may be interested.
Compliance for Governing Boards: This training focuses on the role of Governing Boards in providing compliance oversight. It describes the four actions OIG recommends Governing Boards take to effectively exercise their oversight responsibilities.
Compliance 101: This training gives an overview of compliance, what it is, why it is important, who is responsible for it, where and when it happens, and how to get started with a compliance program for your organization. If you have not thought about compliance before, this training is a great place to start.
Compliance 201 for Grantees: This training, specifically for grantees, goes into greater depth than Compliance 101. It focuses on the Seven Fundamentals of Compliance; important grantee and contract fraud and abuse laws; and the remedies available to the Government if an entity commits violations.
Job Aid
Knowledge Check
Please take the short knowledge check assessment by clicking the link below. After you answer questions about what you’ve learned, you’ll be asked a few questions that can help us improve this course in the future. After you click submit, you’ll receive your Certificate of Completion.