With the passage of the ACA, the voluntary nature of compliance programs is about to change. Smaller healthcare organizations and other ancillary providers who have previously not established compliance programs will now be required to adopt formal programs.  The ACA mandates providers and suppliers participating in federal health care programs to implement compliance programs with “core elements” as a condition of enrollment.

The HHS Secretary is responsible for setting a timeline to implement the new “core elements” for each health care sector and then setting a timeline for providers to adopt compliance programs.  Details regarding the extent of the program have not yet been described or published.  Skilled nursing facilities are the first providers required to implement an effective compliance program by March 23, 2013.

Our Insight.  Your Advantage.  By doing the work now, healthcare organizations can get ahead and avoid surprises when HHS eventually publishes the mandatory compliance program rules for other healthcare sectors. Many in the healthcare industry anticipate the OIG’s voluntary compliance program guidance will serve as an example to HHS as it determines which compliance program elements shall be required.  As you prepare your compliance programs, we recommend that you consider the primary elements of an effective guidance program as outlined by the OIG, which includes the following:

  1. Implementing compliance and practice standards. Policies and procedures should identify specific areas of risk to the organization, provide standards of conduct, and be distributed to people inside and outside your organization who will be affected.
  2. Designating a compliance officer or contact. The OIG asserts that someone within the organization should be designated to coordinate and oversee the compliance program.
  3. Conducting appropriate training and education. Education is an important part of any compliance program. Ideally, education programs should be tailored to the needs of the organization and will include both compliance and specific training.
  4. Developing open lines of communication. The OIG encourages employees to report compliance program violations. The OIG stresses the importance of retaining the anonymity of these individuals where possible.
  5. Enforcing disciplinary standards through well-publicized guidelines.  The OIG asserts that an employer should have consequences for an employee’s failure to follow the compliance program to add credibility and integrity to the compliance program and to make the compliance program work.
  6. Monitoring and audit of compliance system.  The OIG specifically encourages the review of standards and procedures to determine if these standards and procedures are current and complete.  The OIG also recommends review of claims paid by federal health care programs as soon as possible.
  7. Responding appropriately to detected offenses and developing corrective action.  The OIG states that practices may wish to develop their own sets of warning indicators to indicate when billing problems may be present. The OIG recommends self-reporting should be done as soon as possible, upon discovery.