Why Compliance Programs Matter
Healthcare organizations operate in a highly regulated environment, and effective compliance programs help prevent fraud, waste, and abuse while promoting adherence to federal and state laws. The Office of Inspector General, part of the Department of Health and Human Services, has published guidance describing the elements of an effective compliance program.
The OIG Seven Elements
1. Implementing Written Policies and Procedures
Organizations must develop and maintain written standards of conduct and specific policies addressing areas of legal and regulatory risk, such as billing accuracy and documentation requirements.
2. Designating a Compliance Officer and Compliance Committee
A designated compliance officer oversees the compliance program's day-to-day operation and reports to a compliance committee, which typically includes representatives from legal, HIM, finance, and clinical leadership.
3. Conducting Effective Training and Education
Ongoing training ensures that all workforce members understand compliance policies, applicable laws, and how to report suspected violations.
4. Developing Effective Lines of Communication
Organizations must establish accessible channels, such as anonymous hotlines, allowing employees to report concerns without fear of retaliation.
5. Conducting Internal Monitoring and Auditing
Regular audits of coding accuracy, billing practices, and documentation help identify compliance risks before they escalate into significant violations.
6. Enforcing Standards Through Well-Publicized Disciplinary Guidelines
Consistent and fair enforcement of compliance standards, including disciplinary action for violations, reinforces the seriousness of the compliance program.
7. Responding Promptly to Detected Offenses and Undertaking Corrective Action
When violations are identified, organizations must investigate promptly, correct the underlying issue, and take appropriate corrective action, which may include self-disclosure to regulatory agencies when required.
The Role of the Compliance Officer
The compliance officer serves as the organizational leader responsible for developing, implementing, and monitoring the compliance program. This role typically operates independently from the legal department to maintain objectivity and often reports directly to the chief executive officer or board of directors.
Auditing and Monitoring Practices
Coding and billing audits are a core compliance activity, often conducted on a scheduled basis as well as in response to identified risk areas, such as high-denial code categories or areas flagged by OIG work plans.
Reporting Mechanisms
Effective reporting mechanisms must guarantee confidentiality and protect employees from retaliation, encouraging a culture where staff feel safe raising concerns internally before issues escalate to external regulatory bodies.
The HIM Role in Compliance
HIM professionals frequently serve on compliance committees, conduct coding and documentation audits, and provide training on documentation and coding compliance requirements.
Conclusion
The OIG seven elements provide a comprehensive framework for building an effective compliance program that protects healthcare organizations from fraud, waste, and abuse while promoting a culture of ethical practice.