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    Chapter 15

    Learning Objectives

    Elements of a hospital compliance program

    High risk areas of hospital operations

    Hospital-wide Standards of Conduct

    Duties of the hospital Compliance Officer

    Conducting compliance training and education

    Open lines of communication

    Continuously monitor program operations

    Responses to possible compliance offenses

    Example of a hospital compliance plan

    Introduction

    The purpose of a compliance program is to promote adherence to Federal and State laws on fraud abuse, and the program requirements of public & private health plans.

    The Office of the Inspector General (OIG) in the federal Department of Health and Human Services (DHHS) has issued two guidances on the structure and focus of hospital compliance programs.

    Compliance Risks Unique to Hospitals (I)

    Outpatient services rendered in connection with an inpatient stay

    Submission of claims for laboratory services

    Physicians at teaching hospitals

    Cost reports

    Recruitment of physicians to medical staff

    Attracting patient referrals to the hospital

    Admission and discharge policies

    Compliance Risks Unique to Hospitals (II)

    Supplemental payments

    Tax-exempt standards for non-profit hospitals

    Gain-sharing arrangements between a hospital and its physicians

    Antitrust implications of hospital decisions to merge with or acquire each other

    HIPAA Privacy and Security Rules

    Compliance Risks Unique to Hospitals (III)

    Legal implications of trend for hospitals to purchase physician practices, align strategic hospital goals with those of physician practices, and enter into hospital-physician collaborations in support of an accountable care organization (ACO)

    Compliance with EMTALA in the operation of hospital Emergency Departments

    Benefits of a Hospital Compliance Program (I)

    Identify & prevent criminal & unethical behavior

    Ensure false & inaccurate claims not submitted

    Facilitate employee reports of possible problems

    Facilitate investigations of alleged misconduct

    Initiate prompt & appropriate corrective action

    Reduce exposure to civil and criminal penalties

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    Benefits of a Hospital Compliance Program (II)

    Central source for information on fraud & abuse

    Accurate view of employee misconduct

    Identify weaknesses in systems and controls

    Improve quality & efficiency of care delivery

    Build hospital reputation for lawful & ethical behavior

    Elements of an OIG Recommended Hospital Compliance Program

    Standards of conduct, policies, and procedures

    Designation of compliance officer and committee

    Regular education and training programs

    Process to receive complains

    System to respond to complaints and enforce disciplinary action

    Audit and monitor compliance

    Investigation and correction of problems

    Written Policies and Procedures (I)

    The framework of the compliance program consists of written policies and procedures that identify the most critical risk areas in the hospital and prescribe how people should act in those areas.

    Standards of Conduct

    Claims preparation and submission process

    Medical Necessity

    Anti-Kickback and Self Referral Liability

    Written Policies and Procedures (II)

    Bad Debts

    Credit Balances

    Record Retention

    Performance Management

    Compliance Officer (CO) and Compliance Committee (CC)

    CO is focal point for compliance activities throughout the organization

    Full-time, access to CEO and BOD, sufficient staff and resources, adequate authority

    Typical responsibilities

    CC supports the CO in implementing the compliance program

    Typical duties

    Compliance Training and Education

    Training in legal requirements and compliance program that addresses them.

    Directed to hospital’s managers, employees, & physicians.

    Hours per year, condition of employment, documentation of training activities.

    Topics covered by the training.

    Standards for evaluating effectiveness.

    Open Lines of Communication

    Reporting suspected incidents of non-compliance

    Several independent reporting channels

    Protect confidentiality and prevent retaliation

    Criteria for evaluating the communications environment

    Auditing and Monitoring

    To identify non-compliance problems & maintain functionality/effectiveness of the compliance program

    Periodic audits by internal or external auditors

    Risk areas targeted by the audits

    Initial baseline audit followed by regular measures of variations from that standard

    Annual review of program activities

    Responding to Detected Offenses with Corrective Action

    Types of corrective action that may be called for when a violation is discovered

    Value of reporting violations to government agency

    Prevent destruction of evidence and documents

    Factors in assessing how well a hospital deals with detected offenses

    Disciplinary Action for Compliance Violations

    Disciplinary action for violation of laws and compliance policies & procedures

    Range of possible disciplinary actions

    Rigorously screen job candidates to avoid hiring potential violators – looking for recent convictions, debarments, and exclusions

    Review of Real-World Hospital Compliance Plans

    MD Anderson Cancer Center example in book

    Other examples on the internet

    Other examples from local hospitals

    How each example compares to the recommended practices described in this chapter

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