Integrity & Compliance Program Overview

Transcription

1 ELEMENTS OF AN EFFECTIVE DMEPOS ETHICS & COMPLIANCE PROGRAM Are You There? Overview An effective compliance program demonstrates a good faith effort to comply with applicable statutes, regulations, and other Federal health care program requirements, and may significantly reduce the risk of unlawful conduct and corresponding sanctions. OIG, Supplementary Compliance Program Guidance for Hospitals (2005) 1

2 Overview Compliance Program Guidance (US Office of Inspector General) Federal Sentencing Guidelines (US Department of Justice) The federal Healthcare Reform law requires new regulations mandating compliance programs in healthcare. Element #1 Culture & Accountability Formal commitment to ethics and compliance by the Board and senior management. Organizational culture that encourages/rewards ethical conduct and a commitment to compliance. The program is promoted and enforced consistently through use of incentives and discipline. No undue pressure to pursue profit and accomplish goals over compliance. 2

3 Element #2 Designation of a Compliance Officer & Compliance Committee Board of Directors- Oversees the Compliance program, with focus on ensuring that systems and procedures are in place to provide a reasonable assurance of compliance with applicable ethical standards, laws and regulations. Compliance Officer- Implements the compliance program and ensures that the entity complies with applicable ethical standards, laws and regulations. Management Compliance Committee- Advises the Compliance Officer and assists in the implementation of the compliance program. Element #3 Development of Compliance Policies/Procedures/Standards of Conduct Code of Conduct: Comprehensive overview of the program, along with guidance on high-risk areas. Distributed to all Board members, employees, management, contractors and agents. Policies & Procedures: Complete and updated. Well communicated. Education provided. Monitored for compliance. Risk Assessment: Performed routinely. Standardized/formal process. 3

4 Element #4 Developing Open Lines of Communication Culture and practice of non-retaliation. Anonymous hotline and other mechanisms for staff, contractors, subjects, principal investigators and others to report potential issues. All allegations are investigated promptly and thoroughly. Compliance staff are available to provide guidance. Element #5 Appropriate Training & Education Development of a training and awareness assessment and plan. Compliance training is provided to various audiences, including: Board, management, employees, agents and others. Training includes general overviews and high-risk areas. Enforcement of training participation. 4

5 Element #6 Internal Monitoring & Auditing Internal monitoring by operations teams. Independent audits by the compliance department. Detailed and comprehensive audit plans. Able to perform unplanned audits. Audits performed in accordance with government standards. Corrective actions/improvement plans are developed and monitored. Element #7 Response to Detected Deficiencies Prompt and thorough review of actual and potential deficiencies. Corrective action plans are developed to address the root causes. Monitoring is completed to achieve/sustain compliance. Overpayments and other forms of restitution are promptly reported and repaid. Prompt disclosure of issues is made as indicated. 5

6 Element #8 Enforcement of Disciplinary Standards Standards are developed, communicated and consistently enforced. Standards include general compliant behavior, as well as management responsibilities. Compliance is part of the performance review process. Employees, contractors and agents are screened thoroughly. JULENE BROWN, RN, MSN, CHC, CPC ASSISTANT COMPLIANCE OFFICER/DIRECTOR COMPLIANCE OPERATIONS ESSENTIA HEALTH, FARGO, ND Are You There? 6