Health Care Compliance Programs: Stepping Up the Game

This article was republished with permission from Michael Volkov’s blog, Corruption, Crime & Compliance.

The Affordable Care Act was enacted in 2010 – can anyone remember back that far?

The ACA required Medicare and Medicaid providers to have an ethics and compliance program. Congress deferred on the question of timing and implementation of this requirement to HHS. Unfortunately, HHS has not moved too quickly on this issue.

HHS has issued ethics and compliance guidance for skilled nursing facilities, Medicare Advantage plans and Medicare prescription plans. But it has not addressed the big issues relating to providers – from hospitals down to professionals.

Health care companies should be way ahead of the game – in fact, I would be surprised if there were any major providers who have not devoted significant time and effort to the issue.

Health care compliance programs are difficult to design and implement. The stakes are high and the risks are varied. Regulatory compliance, by itself, is a maze of complicated issues, applicable rules, guidance and nuanced distinctions. It is hard enough to focus just on the regulatory compliance issues.

Beyond that basic challenge, monitoring and auditing issues are even more pressing and difficult because of the potential for abuse, as well as mistakes. Medicare revenues can be critical to a provider’s livelihood. Unlike many other industries, medical providers have established careful protocols for providing services, completing paperwork and submitting such materials for reimbursement.

Because of this complexity, the health care industry is a target for fraudsters. There are so many ways to develop complex fraud schemes. As a consequence, auditing and monitoring are even more important than many other risks in other industries.

Once you get past the regulatory challenges, the need to devote time and attention to audit and monitoring strategies, a good question to ask – is there any time left for promoting ethical values and principles? Is there a real risk of compliance fatigue (whatever that term may mean)?

Given this compliance constellation, health care companies should be devoting energy and resources to cutting-edge ethics and compliance strategies. We all know the multifactor list from reams of health care guidance, general compliance principles from the U.S. Sentencing Guidelines and other sources of compliance knowledge and experience. It is time to take those basic ideas and build on top of them – health care companies need to dedicate themselves to new and innovative compliance programs.

If you are reading this and nodding your head, saying to yourself – “of course, we do already,” you are missing my point entirely. Everyone needs to challenge himself or herself, and move their respective programs beyond where they are right now.

What is the first step in this process? From my experience in the health care industry, there is one significant missing ingredient: a lack of Board commitment. Yes, I know the Board is behind compliance 1000 percent, but the question is will they dedicate the resources needed to compliance, and will the Board dedicate themselves to monitoring the program and asking the tough questions? All too often, this is where hospital, clinic and other provider Boards fail.

A Board that is truly committed to ethics and compliance can transform an organization. It quickly translates into a culture and allocation of more resources. Within this environment, hospitals and other providers can develop sophisticated monitoring and auditing strategies, improvement in quality of care issues, minimization of paperwork risks and documentation protocols to minimize risks. The benefit of health care compliance programs does not need to wait for any mandatory regulations – if done correctly, the regulations, when and if released, will be a non-event because compliance programs will be way beyond minimum requirements.