Compliance
Compliance in Healthcare
Healthcare compliance is defined as the ongoing process of meeting or exceeding the legal, ethical, and professional standards applicable to a healthcare organization or provider.
Compliance programs give healthcare providers the tools needed to identify potential risks and areas for improvement in their daily operations. An effective compliance plan makes it easier for practices to comply with regulatory and legal requirements.
STI is committed to a culture of promoting prevention, detection, and resolution of instances regarding compliance that does not conform to Federal and State law. We encourage our clients to adopt a similar approach and to establish a compliance plan to assist in combating fraud and abuse in healthcare in both public and private sectors.
Information provided by STI regarding compliance should only be used as a resource to create your own Compliance Program. We will follow guidelines published by the OIG, and present them in different formats, such as in monthly newsletters and/or on this website. We strive to provide information that will assist you in finding the resources to identify some of the risk areas you may want to include in your newly developed or revised Compliance Plan.
General Compliance Program Guidance (U.S. Dept. of Health – Office of Inspector General)
Fraud (U.S. Dept. of Health – Office of Inspector General)
Compliance Toolkits (U.S. Dept. of Health – Office of Inspector General)
Compliance Program Basics (U.S. Dept. of Health – Office of Inspector General)
Laws Against Health Care Fraud Fact Sheet (cms.gov)
Why does my practice need a Compliance Plan?
An effective compliance program can enhance your organization’s operations, improve quality of care, and reduce overall costs. It can help you to quickly identify problems and do something about them before they become systemic and costly.
What are the seven fundamental elements of an effective compliance program?
- Implementing written policies, procedures and standards of conduct.
- Designating a compliance officer and compliance committee.
- Conduct effective training and education.
- Develop effective lines of communication.
- Conduct internal monitoring and auditing.
- Enforcing standards through published guidelines.
- Respond promptly to detected offences and take corrective action.
Where can I get information on developing a Compliance Plan?
The General Compliance Program Guidance (GCPG) page on the OIG website provides guidance on what you should look for in setting up an appropriate plan. See the link to this page under the Resources tab.
What is the False Claims Act?
- Knowingly presenting a false or fraudulent claim for payment or approval.
- Knowingly making, using or causing to be made or used, a false record or statement material to a false or fraudulent claim.
- Conspiring to commit a violation of the Federal False Claims Act.
What are the Stark Laws?
- Prohibits a physician from referring Medicare patients for designated health services to an entity with which the physician, or immediate family member, has a financial relationship, unless an exception applies.
- Prohibits the designated health services entity from submitting claims to Medicare for those services resulting from a prohibited referral.
What Federal Agencies oversee compliance in healthcare?
- Department of Health and Human Services: the United States Department of Health and Human Services (HHS) is the primary federal agency responsible for protecting the health of all Americans and providing essential human services. HHS oversees a wide range of health-related issues.
- Office of Inspector General: the Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) oversees various aspects of healthcare with a focus on combating fraud, waste, and abuse. It conducts audits, investigations, and evaluations to ensure efficiency and integrity in HHS programs, including Medicare and Medicaid.
- Centers for Medicare & Medicaid Services: the Centers for Medicare & Medicaid Services (CMS), a federal agency within the Department of Health and Human Services (HHS), administers the major healthcare programs.
- Office for Civil Rights: the Office for Civil Rights (OCR) is another branch of HHS. It is responsible for enforcing several key federal civil rights laws that prohibit discrimination in healthcare and social service programs.
- Occupational Safety and Health Administration: the Occupational Safety and Health Administration (OSHA) oversees a wide range of safety and health issues in the healthcare sector.