Compliance Planning

Compliance Planning

1. Implementing Written Policies, Procedures, and Standards of Conduct

Due to the massive amounts of money being used in activities such as fraud, the government is putting in place policies that will make sure this no longer happens. The health care market is one of the largest sectors and works for the betterment of people, which means their primary responsibility is to save the government money. This can only be done successfully if the amount of fraudulent and abuse activities is reduced significantly. The types of services that are provided by the healthcare market sector are as follows: medical treatment, health care services, health, and medical information, and insurance payment of health care.

Three health care finance policies could be:

1. inaccurate payment allocation for services that have not been rendered
2. reimbursement or payment for services that have been monetarily charged at a low rate (up-coding).
3. Charging unduly for services or provisions

By being non-compliant with any of the three major Medicare frauds, you will be prosecuted to the full extent of the law based on which policy you break. If you have proof or suspect one of the policies is being violated, you must report this to your supervisor or another manager, or the compliance officer.  If the incident is not reported, you will be an accessory to the broken policy. If you are asked to do any of the prior listed forms of fraud, you must report it also, or you will be prosecuted. If you feel you are unable to report an issue or suspicion to your manager or supervisor, call the fraud helpline.

1. Element Two: Designating a Compliance Officer and Compliance Committee to Provide Program Oversight

Job Description of Compliance Officer

A compliance officer is a person who supervises and works as a separate and objective body that analyses and assesses compliance issues/concerns in the organism. The position guarantees the Board of Directors, management, and employees are abiding by the laws and regulations, as well as company guidelines. The compliance officer also guarantees compliance with company conduct standards in the institution.

The Corporate Compliance Office acts:

• As a communication channel, compliance issues are discussed and resolved to suitable investigation and resolution assets
• As a final administrative asset, that can be communicated by interested parties after other formal channels and resources are depleted.

Job Tasks

• Evolves, triggers, and preserves policies and processes, including modifying them.
• Manages day-to-day program functions.
• Progresses and occasionally evaluates and upgrades company performance standards
• Collaborate in the application of compliance issues by current investigative and resolution streams with other agencies (e.g., risks management, internal auditing, employee services, etc.).
• Reacts to perpetrated violations of rules, restrictions, policies, processes and conduct standards
• Provides periodic reports as aimed or demanded to educate the Board of Directors and Senior Management Corporate Compliance Committee of the functioning and advancement of compliance efforts.
• Guarantees that violations or potential violations are reported correctly and/or requested to duly authorized enforcement agencies.

Job Experiences

Education: A bachelor’s degree required; Master’s desired

Experience: A minimum of 10 years’ experience in a healthcare organization along with,

• Established leadership
• Understanding of operational, financial, quality assurance, and human procedures and regulations is a must.
• Excellent communication skills
• Team management skills
• Attention to detail

Compliance Committee

The compliance committee should meet monthly or quarterly as needed to review and discuss significant cases from the prior period. Actions include, frequently reviewing and updating policies and procedures as required, establish and maintain policies and procedures, conduct reviews and field audits, report findings, and report suspected fraud, waste, and abuse. There should be at least five members which consist of the board of directors and committee members. The best method of communication is through email or in person.  The compliance committee consists of representatives from primary departments to include but not limited to Quality Management/Assurance, Compliance Department, Claims, Clinical, Information Technology, Credentialing, and the HIPAA Compliance Officer.

1. Educating Employees and Developing Effective Lines of Communication

There will be emails to disseminate information, posters within every department in the company, monthly and quarterly newsletters, and a compliance question that pops-up upon logging in for every employee. All employees should have training at least once a month to refresh their memory of the rules and code of conduct. New employees should be appropriately trained and make sure the company’s policies are clear and understood. The training session should be at least one day since it is a lot of information. There will be consequences for anyone who did not attend and was not excused. Those who missed training will have a make-up day. A typical training session agenda will be as follows:

Agenda

• Introduction
• Purpose
• Objectives
• Informational Segment (segments would change depending on the monthly calendar)
  • Eyewash Stations
  • Safety/Fire Safety
  • Laboratory Care
  • Compliance Audit
• Test for knowledge
• Receive a certificate of training

A significant concern for the compliance committee would be the reporting of any

fraudulent and abusive activity. There will be a service where employees can send anonymous complaints, so their identity will be protected. There will be a contact number that will have a live person 24/7 to receive all complaints. A Compliance Officer will be notified and will report non-compliance to all required individuals, which include federal and state officials, if applicable. An immediate investigation, along with audits and document reviews, will also take place. Concurrently, disciplinary action will be taken, policies and procedures will be reviewed, and mandatory training will occur for each alleged incident of non-compliance.

1. Element Five: Conducting Internal Monitoring and Auditing

Internal Monitoring and auditing will be done daily. Because fraud activities are mostly conducted inside the organization, everyone will be looked at carefully.

Healthcare fraud, abuse, and compliance calendar template

1. Enforcing Standards Through Well-Publicized Disciplinary Guidelines

1. Who is covered: Anyone who is committed criminal activities within the organization.
2. Standards of conduct: The complaints that were sent in should be monitored and handle in an orderly way (high-risk to low-risk)
3. Discipline and Enforcement: The organization should try to maintain a non-fraudulent company and continue to enforce this.
4. Reporting: Should continue to remain anonymous.

1. Responding Promptly to Detected Offenses and Undertaking Corrective Action

When responding to detected offenses, the response could be as follows:  There has been a complaint of a violation of our companies’ fraud, abuse, and compliance regulations.  Please report to your compliance officer for further information regarding this matter.  You have two business days to respond to this notice.

1. Administrative Actions: reporting, warning letters, investigations, audits, and document review
2. Disciplinary Actions: suspension, payment, and termination
3. Policies and Procedures: review, revise, and publish
4. Training: mandatory training and education materials

References

Career Resources. (n.d.). Retrieved from http://www.ache.org/newclub/career/comploff.cfm

Healthcare fraud in 2015: Running list. (n.d.). Retrieved from https://www.healthcarefinancenews.com/slideshow/biggest-healthcare-frauds-2015-running-list?p=5

Loughran, M.A (2017, January 11). Health-Care Policy, Fraud, and Abuse Head 2017 Top 10 List.  Retrieved from https://www.bna.com/healthcare-policy-fraud-n73014449681/