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Defining Healthcare Compliance

In these times of increasing regulatory enforcement, many organizations are striving to build an effective compliance program. The starting point for any organization is to understand what compliance really means and how it is defined. Organizations may wish to consider the following definitions and background to gain a better understanding of health care compliance.

What is Healthcare Compliance?

Healthcare compliance can be defined as the ongoing process of meeting or exceeding the legal, ethical, and professional standards applicable to a particular healthcare organization or provider. The Department of Health and Human Services (HHS) Office of Inspector General (OIG) has helped to define healthcare compliance through their compliance guidance documents. This guidance calls for efforts to establish a compliance culture within organizations. A culture of compliance promotes prevention, detection and resolution of instances of conduct that do not conform to government laws, public and private payor healthcare program requirements, and ethical and business policies.

The Scope of Healthcare Compliance

The scope of compliance extends to many areas including patient care, billing, reimbursement, managed care contracting, research standards, OSHA, The Joint Commission standards, and HIPAA privacy and security, to name a few. Healthcare compliance means meeting all of the rules and requirements applicable to an organization across a broad range of criteria, and that may vary considerably depending on the type of organization and the services it provides. The biggest challenge for healthcare organizations and their compliance officers is to keep track of all the requirements and regulations, which are extremely numerous.

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Effective Compliance Programs

Effective compliance programs are defined as those that avoid or minimize liabilities, including legal or regulatory penalties and potential civil litigation. The challenge for developing an effective program is complicated by the ever-changing legal and regulatory environment. New laws and regulations come into play on a daily basis from all levels of government. To avoid having an ineffective compliance program, healthcare organizations and providers should develop effective processes, policies, and procedures to define appropriate conduct, train the organization’s staff, and then monitor the adherence to the processes, policies, and procedures. For most organizations, the biggest challenge is to evidence compliance program effectiveness, especially using verifiable metrics, and identify any gaps in the program.

The Changing Healthcare Compliance World

It is nearly impossible to define the extent or complexity of the ever-changing healthcare compliance world. New laws and regulations come into play on a daily basis from all levels of government. Some of these have far-ranging implications such as the Anti-Kickback Statute, Stark Laws, False Claims Act, and HIPAA and HITECH laws that are designed to protect the privacy of patient information. As noted above, compliance programs should promote not only compliance with these rules, requirements and standards of ethical conduct, but also a culture that promotes prevention, detection, and resolution of conduct that does not conform to these requirements.

Looking for Help Managing Your Compliance Program?

Keeping pace with rapidly changing federal regulations can be difficult for many health care organizations to manage. Strategic Management Services offers outsourced compliance officer services and many other consulting services to help support your compliance program’s individual needs. For questions about our compliance program services, please feel free to contact our experts online, or give us a call at (703) 683-9600.

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