Just Because It Isn’t Raining Doesn’t Mean You Shouldn’t Have An Umbrella

By Seasons | April 21, 2021

deskCompliance isn’t Reactive! 

As savvy healthcare professionals know, effective compliance isn’t somebody else’s problem. Knowing the basic terminology, areas of focus, and where these federal rules apply is a solid start. But having a general understanding is just the beginning.

Compliance Programs are Required, and They Minimize Risk.

The Affordable Care Act (ACA) requires healthcare providers who participate in Medicare, Medicaid, or CHIP programs to have an established compliance program. However, even if these weren’t requirements of the ACA, they would still have tangible benefits for a provider:

  • Compliance programs can mitigate fines and penalties: The US Sentencing Commission Guidelines Manual specifically identifies “the existence of an effective compliance and ethics program” as one of two factors that could mitigate the punishment of an organization. For the healthcare industry, this means that a compliance program could reduce fines for violations of fraud, waste, and abuse laws like the False Claims Act – provided that the compliance program is actually robust and effective and not just a document pulled out of the drawer for review a few times a decade.
  • Self-reporting can also reduce penalties: Compliance programs are intended to identify potential fraud, waste, and abuse. When those issues are identified, providers have an obligation to self-report the issue to the government and repay any amounts to which the provider was not entitled. This is not only mandated by law, but also helps mitigate any potential fines/punishment associated with the conduct that was fraudulent, wasteful, or abusive of the federal healthcare programs. Essentially, you get credit for having the integrity to come forward and admit a mistake.
  • Qui tam? Not quite: Qui tam cases (sometimes referred to as ‘whistleblower cases’) are often brought by current or former employees who may believe their organization is not taking compliance seriously and has committed some form of fraud, waste, or abuse. When interviewed, qui tam relators/whistleblowers commonly indicate they may not have brought their lawsuit if their organization had promptly and thoroughly investigated their concern, remediated any issues found, prohibited any retaliation, and communicated those steps to the whistleblower to the extent possible. An effective compliance plan mandates these investigations and subsequent steps, which can reduce the incidence of qui tam cases.

Watch Compliance 101 on demand now for CE/CME credit

5 Best Practices For Your Program

There are no shortage of tools to help you understand what your compliance program needs to get going. The important thing to remember is that the most impactful compliance programs are ongoing, living programs. They require oversight, monitoring, and should be woven into the cadence of your practice. Compliance isn’t a binder that gets used when a surveyor walks in, it’s a way of running your business every day.

It doesn’t rain every single day, but that doesn’t mean we will never get wet. Knowing that your program might be compliant today doesn’t necessarily indicate that ongoing vigilance isn’t needed. Developing regular accepted methods of ensuring you’re being a wise steward of federal healthcare dollars with every patient is key to the viability of your critical work serving patients.

Interested in learning more? Join our 5/4 live webinar on case studies
from healthcare organizations that didn’t prepare!

Learning from Others’ Mistakes –   Compliance Through Case Studies

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