Have You Evaluated Your Compliance Program Lately?

The new administration released its Budget Blueprint for the fiscal year 2018. An interesting item of importance is the increase in funding for the Health Care Fraud and Abuse Control (HCFAC) program, a national program under the control of both the Department of Justice (DOJ) and the Department of Health and Human Services (HHS). The HCFAC program is designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse. This indicates that health care fraud enforcement will remain a priority for the new administration. Health care organizations should take note and consider evaluating their compliance programs. To help evaluate your compliance program, there have been two recent resources released by Federal government agencies that health care organizations should consult.

On February 9, 2017, the Fraud Section of the DOJ’s Criminal Division published a compliance guide describing specific factors that prosecutors should consider when conducting an investigation of a company, determining whether to bring charges, and negotiating plea deals. The guide asks several direct questions that health care organizations should consider when investigating or responding to a compliance breach. The questions are grouped by the following topics:

  1. Analysis and Remediation of Underlying Misconduct;
  2. Senior and Middle Management;
  3. Autonomy and Resources;
  4. Policies and Procedures;
  5. Operational Integration;
  6. Risk Assessment;
  7. Training and Communications;
  8. Confidential Reporting and Investigation;
  9. Incentives and Disciplinary Measures;
  10. Continuous Improvement, Periodic Testing and Review;
  11. Third Party Management;
  12. Mergers and Acquisitions (M&A).

On March 27, 2017, the Office of Inspector General for the U.S. Department of Health and Human Services (OIG), in conjunction with the Health Care Compliance Association (HCCA), released a resource guide to assist health care organizations in assessing the effectiveness of their compliance programs. This resource is a byproduct of a recent roundtable discussion between compliance professionals and the OIG that met for the purpose of determining ways to measure effectiveness of compliance programs. The objective was to identify ideas about what and how to measure compliance with respect to the seven elements of a compliance program identified by the Federal Sentencing Commission. In the release of this resource, the OIG emphasizes this is not a checklist or a best practice template but a resource to consider when developing and evaluating a compliance program. The resource lists detailed and comprehensive compliance program metrics with the expectation that each health care organization will choose the metrics that best suit its needs. The seven key areas identified in the resource include the following:

  1. Standards, Policies, and Procedures;
  2. Compliance Program Administration;
  3. Screening and Evaluation of Employees, Physicians, Vendors and Other Agents;
  4. Communication, Education, and Training on Compliance Issues;
  5. Monitoring, Auditing, and Internal Reporting Systems;
  6. Discipline for Non-Compliance; and
  7. Investigations and Remedial Measures.

Both the DOJ and OIG resources emphasize the importance of having an effective compliance program. If you have any questions, or if you would like additional information about this topic, please contact either Bob Wilson or Ashley Thomas.

You can access the DOJ resource here.

You can access the OIG resource here.