Importance of Comprehensive Compliance Programs
During the course of an internal audit, a Northeast hospital system identified malpractice issues of false claims in one of its teaching hospitals. The audit, which was part of the hospital’s voluntary compliance, uncovered a lack of documentation and upcoding in the teaching hospital (Filerman, Mills & Schyve, 2014, p.211). The hospital acted promptly to resolve its False Claim Act liability. The disclosure by the hospital to the government of the malpractice and the preexisting comprehensive compliance program made the Office of the Inspector General (IOG) not to impose a corporate, institutional, or individual integrity agreement (CIA).
The False Claim Act
The False Claim Act is a federal healthcare regulation that imposes liability to companies and individuals that defraud government programs. False claims as a result of upcoding (billing of services at a higher price), double billing of medical services or procedure, billing of services not rendered, and billing of unnecessary procedures are some of the violations of the Act (Androphy, 2018). Violators often get fines for each false claim. Additionally, the Act has provisions that allow for whistleblowing by persons unaffiliated with the government. The violation committed by the teaching hospital was upcoding and others that may result from a lack of documentation such as billing of services not rendered. The IOG is the regulatory government agency body tasked with combating fraud by ensuring compliance of healthcare organizations with relevant healthcare laws.
Importance of Comprehensive Compliance Programs
Healthcare fraud and abuse is a significant challenge facing the U.S. healthcare system. Medical fraud rates continue to rise despite an increase in governmental inquiry, audits, and investigations (Beesley, 2019). A comprehensive compliance program is an effective defensive mechanism strategy, as seen in this case. A compliance program aims to prevent criminal conduct and enforce healthcare rules and regulations. It can help address malpractices such as fraud and abuse, among others. The Affordable Care Act (ACA) requires hospitals to implement comprehensive compliance programs for eligibility to enroll in the Medicare program. Also, many commercial insurance plans require providers to implement comprehensive compliance plans to qualify for participation. According to the Centers for Medicare and Medicaid Services (CMS), when a provider implements a good compliance program, they help protect the organization from the risk of improper conduct.
The Role of Compliance Manager
The compliance manager has the authority to develop and oversee the compliance program within a healthcare facility, implement recommendations by the compliance audit and risk assessments, and set the best practices that adhere to all required standards (Beesley, 2019). The manager is the go-between person between the management and the compliance team and is in charge of compliance education and training programs for all healthcare staff. The compliance manager works closely with the compliance analyst and compliance auditor.
Ethical Issues
A healthcare organization needs to have procedures, protocols, and policies in place that govern ethical issues. A hospital’s Code of Ethical Conduct specifies that healthcare professionals should adhere to (Board, 2014). All healthcare professionals must go beyond the regulatory and legal requirements in exhibiting ethical behavior. Practicing ethical behavior such as refraining from fraud and abuse is of the obligations that the Code of Ethical Conduct places on healthcare professionals.
Summary of Learning
Healthcare fraud and abuse is a significant challenge facing the healthcare system. The False Claim Act is a federal imposes liability to companies and individuals that defraud government programs. False claims include upcoding, among others. A compliance program aims at promoting the prevention of fraud and abuse and enforcing healthcare regulations while offering quality care to patients. The roles of the compliance manager include developing and overseeing the compliance program within a healthcare facility and implementing recommendations by the compliance audit and risk assessments. A hospital’s Code of Ethical Conduct specifies that healthcare professionals should adhere to and helps prevent malpractices by requiring healthcare professionals to act ethically.