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Compliance Has Changed

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07/25/2017
Billing: The Journal of the Healthcare Billing and Management Association

Feature Story




HIPAA Change

In March 2017, the Office of Inspector General (OIG) of Health and Human Services collaborated with the Health Care Compliance Association (HCCA) to provide what is arguably the most important compliance document for our industry since 1998: Measuring Compliance Program Effectiveness: A Resource Guide (oig.hhs.gov/compliance/ 101/files/HCCA-OIG-Resource-Guide.pdf). This document is a practical, scalable, and environmental scan of how successful our compliance efforts really are. It is intended to recognize the customization required for an effective compliance program while also recognizing the various ways the seven elements are implemented and addressed in each of our organizations. Compliance professionals are encouraged to target the element of the guide to their professional need in their organization and to “keep in mind the importance of incremental gain.”

A Step Back in Time
In 1998, when the OIG published Compliance Program Guidance for Third-Party Medical Billing Companies, compliance guidance was relatively new, and few, if any, companies had implemented what are now known as the “seven elements of effective compliance.” The guidance was our initial road map for developing compliance programs. Having an effective compliance program to prevent and detect issues of non-compliance was considered so important that it was a sentencing consideration under the Federal Sentencing Guidelines. In the many years since then, the OIG has published more industry-specific compliance guidelines as well as related compliance tools, alerts, and educational programs. In addition, many other guidance documents have been published to help our industry build and maintain cultures that are the backbone of effective compliance programs.

Fraud The next significant development was Chapter 8 of the Federal Sentencing Guidelines, which was revised to place a focus on ethical cultures. www.ussc.gov/guidelines/2016-guidelines-manual/2016-chapter-8 Today, compliance is not new, and we are no longer in a learning and building compliance programs industry. Daniel Levinson, OIG Inspector General, stresses that to have any effective compliance program, we must teach our employees to think. Thinking employees, who really understand compliance related to their work and duties, build an ethical culture. A top-down approach has long been a compliance focus, but it is truly a vertical and horizontal—top-down and bottom-up environment—that works. Every single person must know what is right and act accordingly. Our takeaway should be to focus on ethical people, not just marking boxes on check lists.

Managers— “middle managers” in particular—have long been recognized as the Achilles’ heel of many compliance programs. Management accountability has now become a core requirement of Corporate Integrity Agreements. We are obligated to look thoughtfully and carefully at the people we entrust to manage our operations in a compliant manner. It does not matter if we are the largest company in the RCM industry or the smallest—the expectation for compliance knowledge and ethical action is the same. The manager accountability requirement is explicit in settlements with the governmental agencies.

The Department of Justice (DOJ) has also published sample questions that they rely upon when evaluating compliance program effectiveness. DOJ clearly recognizes the wide variability of organizations and that no two compliance programs will or should look alike. One of their key assessments is whether compliance is embedded in every facet of operations in the organization. Like OIG, their focus seems to be on starting points and the subsequent progress made over time commensurate with new guidance, laws, and as a result of your own ongoing risk analyses. www.justice.gov/criminal-fraud/page/file/937501/download


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Over time it can be easy to become complacent and confident in what we have built. If we have never had a problem, does that mean everything is as it should be? Or do we just not know what we don’t know? After all, 1998 was a long time ago, and there’s nothing really that new. Right? Wrong! A program may be working just fine. However, if we have not kept pace with industry expectations, deficiencies may not be evident. The HBMA Compliance Symposium has been designed to help our members better understand the changes and requirements over the years since the 1998 OIG guidance was published. The faculty strives to provide thought-provoking topics that will help attendees reevaluate their program effectiveness and culture of compliance. We are all on a unique journey due to our organization or company size, types of clients, services provided, and unique risks that result. Regardless of whether our members are new to compliance or seasoned veterans, compliance today is not what it was in 1998 when we began building our compliance programs. Compliance has changed.


Holly LouieHolly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and past president of HBMA.