Health Care Compliance
Healthcare compliance is a government strategy that aims at ensuring that patients receive the necessary, safe, quality, efficient and effective medical care in all hospitals. Healthcare compliance involves following a set of rules and regulations that are set explicitly for the healthcare industry. Compliance protocols include patient safety, privacy and ensuring that medical institutions do not overcharge their patients. However, healthcare protocols vary in different states within the United States of America. Healthcare compliance gives patients the confidence to check into a hospital and receive the treatment they deserve. Also, the agreement gives them the confidence to share their personal information with medical professionals since they are aware of the hospital’s privacy protocols. UPMC Children’s Hospital of Pittsburgh has to follow the stipulations of compliance agencies to ensure that they continue being the leading medical institution in providing quality care for children, teens and young adults throughout the state of Pennsylvania.
Healthcare compliance agencies help organizations such as UPMC to follow the growing need to follow government regulations that ensure patient safety, privacy, storage of patient information and protection of the well-being of medical staff at the organization. The enforcement of state legislation runs under the Office of the Attorney General, while federal laws are under the Office of the Inspector General in the U.S. Department of Health and Human Services. The various organizations and governing agencies that ensure that UPMC complies with the requirements of both federal and state laws include:
The U.S. Department of Health and Human Services (HHS)
HHS is a government agency under the Office of the Inspector General in the USA that ensures the protection of patients’ privacy, provision of quality medical services and reduction of fraud in healthcare organizations. The department also ensures that hospitals comply with federal healthcare laws and set programs. The Healthcare Information Portability and Accountability Act (HIPAA) of 1996 stipulate standards in the healthcare industry and provide a process for the protection and handling of patient health history. Under the Department of Health and Human Services, the Health Information Technology for Economic and Clinical Health Act (HITECH), through its implementation in 2009, addresses the sharing of electronic health records (EHR). HITECH with HIPAA ensures that medical facilities protect patient information and allows HHS to carry out periodical audits and penalty adjustments. Any institution that does not comply with these regulations is liable to a fine of up to $1.5 million.
The Emergency Medical Treatment and Labor Act (EMTLA) under HHS ensures that all American citizens can receive emergency medical services irrespective of their medical insurance cover or ability to cater to the services. EMTLA provides that all the allow Medicare can give patient emergency services, including screening and stabilizing treatment incase of abrupt health issues. The Patient Protection and Affordable Care Act (ACA) ensures that organizations charge a reasonable fee for medical services. Also, ACA outlines quality and service efficiency programs such as the Medicare Shared Savings Program for establishing Accountable Care Organizations (ACOs). Together with the association of physicians, healthcare institutions, ACOs keep the cost of healthcare within a manageable limit and enhance patient results, which ensures that patients pay for value instead of service.
Centers for Medicare and Medicaid Services (CMS)
The CMS, under the U.S. Department of Health and Human Services (HHS), holds the responsibility of administering Medicare, Medicaid and Children’s Health Insurance Program (CHIP). The administration of all these programs involves a series of compliance protocols and reimbursement strategies that medical institutions have to follow. CMS also includes the Electronic Health Record (EHR) incentive programs, which provides regulations that ensure organizations are in lin with HITECH standards in the handling of patient information. The 2015 Medicare Access and CHIP Reauthorization Act (MACRA), including the Quality Payment Program and Merit-Based Incentive Payments System (MIPS), ensures that the refunds have a basis on quality patient care and results.
Medicaid Fraud Control Units (MFCU) are responsible for the investigation and prosecution of insurance frauds in the healthcare industry by looking at cases of patient abuse and neglect in the medical facilities. Also, MCFUtakes the necessary action to ensure that they get the justice they deserve. Every state in the U.S., including Pennsylvania, has MFCU in the office of the Attorney General, which has the responsibility of ensuring that institutions abide by federal and state laws in conjunction with the Office of the Inspector General. Healthcare facilities, in some cases, have to set up Medicaid fraud control offices within the institution, which indicates their level of compliance. Besides, the Federal Anti-Kickback Statute prevents medical professionals from taking bribes from federally insured patients under Medicare and Medicaid.
Occupational Safety and Health Administration (OSHA)
The OSH Act of 1970 within the U.S. Department of Labor protects the medical staff and the general public. The agency sets regulatory standards that enhance the safety of the therapeutic environment. OSHA comes up with compliance protocols that include safe handling of x-ray machines and disposal of infectious agents that can cause diseases. Together with the Center fo Disease Control (CDC), OSHA comes up with protection strategies that are essential I containing the spread of infections in the case of an epidemic. Besides, OSHA ensures that organizations provide their medical personnel with the necessary protective gear to minimize exposure to infectious agents.
Non-compliance of legislation in the healthcare industry involves situations where the leaders of the facility do not follow either state or federal regulations. In most cases, when organizations breach the requirements of healthcare compliance agencies, they risk losing up to $1.5 million because of the inability to abide by the set laws. Thus, there is a possibility of income reduction because of settling legal suits. Also, an organization risks losing its credibility because patients are not likely to visit a hospital that does not follow government protocols to ensure their safety and protection of their privacy. Besides, the inability of an organization to support government and state regulations can result in revocation of practice licenses resulting in the closure of the organization. However, organizations can provide specialized training to their staff to ensure that they are aware of the policies and strategies that are essential in their field. Also, the healthcare institution has to keep updating their medical professionals of any changes in healthcare regulations. Besides, healthcare organizations can pay for their professionals to attend compliance courses, which help in ensuring that the institution maintains its compliance standards.
HHS monitors and measures healthcare compliance in different ways. The include gap analysis, which compares performance with possible and desirable results by looking at the strengths and weaknesses of organization leaders to understand the possibility of non-compliance. Also, federal and state agencies can assess I.T. security within an organization to understand their investment in compliance. Compliance agencies can carry out security risk analyses (SRAs) on behalf of organizations to determine their risk management strategies. Audits are essential in enforcing compliance strategies that are in line with business privacy and security rules. Healthcare organizations such as UPMChave to set clear protocols concerning patients’ safety, confidentiality, and quality services to ensure that the staff are aware that the institution is compliant with federal and state laws.
In conclusion, UPMC has to follow the requirements of federal and state agencies to be able to run their services smoothly. Protection of client data, provision of quality services and patient safety ensures that the organization maintains its credibility as the leader of pediatric care throughout Pennsylvania. Also, compliance ensures that UPMC does not have to go through a loss resulting from lawsuits. Besides, the installation of state-of-the-art I.T. protocols allows UPMC to avoid cases f cybercrime such as hacking, which can lead to loss of patient data.