By: Jacqueline Bain
I had a law school professor who repeatedly referred to his class as “Doom at Noon.” The topic was dry, the cases were boring and, if not for the professor himself, the class would have been unbearable. I think of that, all these years later, every time I have to counsel a client on a topic that makes his or her eyes glaze over, like healthcare compliance.
Compliance means that you’re operating within the bounds of law. Sure, it sounds boring, but it’s a giant undertaking for any business, and especially for one so regulated as healthcare. Over the last three decades, the Department of Health and Human Services’ Office of the Inspector General has urged the private healthcare community in to take steps to combat fraudulent conduct and prevent the submission of erroneous claims.
Why Worry Now?
Why does your healthcare business need to be proactive about compliance? Quite simply, you cannot afford not to. During fiscal year 2016, the Federal Government won or negotiated over $2.5 billion in health care fraud judgments and settlements. That’s in addition to attaining additional administrative impositions in health care fraud cases and proceedings. The Department of Justice opened 975 new criminal health care fraud investigations. Federal prosecutors filed criminal charges in 480 cases involving 802 defendants, and a total of 658 defendants were convicted of health care fraud-related crimes.
And the Federal government has coordinated its efforts with State governments in recent years to redouble enforcement efforts. Since 2012, Federal Government, State officials, law enforcement, private health insurance plans and associations, and health care anti-fraud associations have been working together under the Healthcare Fraud Prevention Partnership (HFPP). The purpose of HFPP is to exchange data and information between all participants to help improve capabilities to fight fraud, waste and abuse in the healthcare industry.
Where to Start
How do you know which laws you must comply with? How do you operate your business to obey the laws? Who is in charge of making sure all of this happens? What do you do if a non-compliant act is discovered? How much of this, exactly, is each employee supposed to know? (Have your eyes glazed over yet?)
Lucky for you, we are really jazzed about compliance and prescribing ways for your business to incorporate it. Using regular, internal controls to more efficiently monitor adherence to applicable statutes, regulations and program requirements not only keeps your business out of trouble, it also helps the business to function more efficiently and, yes, profitably.
Think of a world where you’re happy to see the Joint Commission show up (or, at least, not terrified). Or where a payor asks to see your billing policies and procedures and you don’t have to think twice before handing them over. This is what can be accomplished with effective compliance within your business.
The OIG has laid out seven components of an effective compliance program:
- Putting in place written policies, procedures and standards of conduct.
- Designating a compliance officer and compliance committee.
- Conducting training and education.
- Developing lines of communication.
- Conducting internal monitoring and auditing.
- Enforcing standards through disciplinary guidelines.
- Responding promptly to detected offenses and undertaking corrective action.
Compliance shouldn’t be overly burdensome. Chances are, your business already has some of these components in place. Someone just has to fish around in there and bring each component you already have forward in an easily digestible way, and then supplement with components you haven’t yet achieved. Just a couple of conversations and you can get back down to business.
No, legal compliance isn’t sexy, but for healthcare businesses, it is a necessary component of everyday operations. Think of it as required reading.