Healthcare Business Management Association - HBMA
Leading the Business of Healthcare Login
HBMA News HBMA News - HBMA Healthcare Business Management Association

Is Your HR Department Part of Your Compliance Program?



Is Your HR Department Part of Your Compliance Program?


Compliance Starts with Human Resources

If your HR department is not currently part of your compliance program, it most certainly should be, regardless of your affiliation or industry. The HR department is the first face an onboarding employee sees; it therefore sets the tone for the culture of compliance. There should be a direct ongoing communication line from the HR department to compliance at all times. There are many documents within HR that relate to compliance—some you may not even realize play an extremely important role with compliance.

Job Descriptions

During the course of my performing risk assessments across the nation, it was astounding to me how many medical practices do not have job descriptions for their employees. A job description is an essential document for onboarding, job classification, access control, and accountability. Crafting a compelling job description helps medical organizations, regardless of size, attract the most qualified candidates for open positions. The key to writing effective job descriptions is to find the perfect balance between providing enough detail so candidates understand their role and your company's employment expectations while keeping your description concise. There are aspects of a job description that will show how imperative it is that the HR department interrelates with compliance including:

Ideally, when a potential employee candidate comes to your office to interview for a position they should be provided with a job description prior to the interview. A job description should describe the title of the position, job classification, roles and responsibilities, expected education needed to qualify for the position, and physical demands for completing the position. Prior to the interview the candidate should be provided an opportunity to read, acknowledge, and sign off on their understanding of the position for which they are applying. Should the candidate be hired, the signed job description will need to be kept in the employee's personnel file.

Job Classification
Job classification is a critical component of a job description. The goal here should be to ensure proper administration of compensation, as well as benefits and determination of their employment status.

Employees need to be correctly classified for purposes of federal and state wages, and hour and benefits laws. The Fair Labor Standards Act (FLSA) requires that employers classify employees as either exempt or nonexempt to determine whether an employee is entitled to overtime pay under the FLSA. The Employee Retirement Income Security Act (ERISA) makes the classifications of full-time, part-time, temporary, and seasonal employment important for benefits purposes.

Nonexempt employees are employees whose work is covered by the FLSA. They are not exempt from the law's requirements concerning minimum wage and overtime.
Exempt employees are generally executives or managers, or professional, administrative or outside sales staff who are exempt from the minimum wage and overtime provisions of the FLSA. Exempt employees hold jobs that meet the standards and criteria established under the FLSA by the U.S. Department of Labor.

Access Control
Once an employee has been hired, the HR department should utilize the job description to determine what system access is required for him or her. This will ensure the minimum necessary access to PHI is issued to the employee to perform their job effectively and in compliance with HIPAA and HITECH regulations.

An essential part of employee engagement is to ensure appropriate resources are provided to all employees. This allows them to perform his or her position to the best of their ability, and helps to build productivity. The HR department would not be able to hold employees accountable for lack of productivity or poor work performance without having an effective job description, as well as any necessary training and education.


Training & Education

Training is an essential element of a compliance program and interrelates with HR. If a medical organization's employees are not aware of compliance laws and office policies pertaining to their specific job descriptions, you can't hold them accountable for the problems they may unwittingly create.

Here are a few best practices for ensuring your employees receive appropriate compliance training:
  • Have a job description for every position;
  • Define effective and engaging training that coordinates with your employees' job descriptions;
  • Motivate your employees to learn more; and
  • Track and document employees' training.

Measure Training Outcomes

To develop ongoing training that fulfills education requirements, best practices include the measurement of outcomes and determining whether current teaching methods are effective. For training to be effective, it should make a strong impression, produce a response from your employees, and be useful. It is imperative to conduct competency testing to measure an employee's comprehension of the training. It's always a good idea to do pre- and post-training questionnaires to determine an employee's engagement during the training. This is also a great way to determine how effective the training was and/or determine if the trainer did a good job. Medical organizations should also provide employees with an avenue for expressing opinions about the training and for suggesting future training or resources that will help them.

Overall, training should be delivered, received, understood, and retained effectively. There is a variety of teaching methods you can use. A few examples are:
  • Interactive training;
  • In-person training sessions;
  • One-on-one training;
  • Group training; and
  • Monthly newsletters or bulletins.

Compliance Training

Compliance training is an essential element of a compliance program and absolutely interrelates with HR. If a medical organization's employees are not aware of compliance laws and office policies pertaining to their specific job descriptions, they would not be able to hold employees accountable for non-compliance or any ignorance of federal and state regulations.

All personnel, employees, leadership, independent contractors, and agents should be educated on the significance of your compliance program. Be sure everyone understands that the goal is to ensure a culture of compliance within your organization. As with any change in an organization, if employees are aware of why and how new policies will affect them personally, they will be less resistant to the changes.

Everyone should be educated in their role and adhere to the medical organization's compliance program. They should understand their duty to report misconduct, the procedures and methods to report suspected misconduct, confidentiality, when and where confidentiality ends, and the non-retaliation policy for good faith reporting.

Each person in each department should be educated and trained in the specific areas applicable to their respective department. All new employees should receive initial training regarding the compliance program and specific job-related compliance training as soon as possible after their date of hire.

Documentation Is Key

All training needs to be documented. Internal and external education and training updates for all staff members should be required at least annually (HIPAA and OSHA training is mandated annual training). These updates include making changes to your compliance program, holding job-specific seminars, attending Medicare and Medicaid insurance update conferences, among others. It's best practice to keep a record of when training takes place along with list of attendees. It is a good idea to have all attendees sign a log to confirm attendance.

All training and education needs to be based off of best practices and federal guidelines for compliance. Each module of education should consist of some type of interaction with the attendees to keep your employees engaged in the learning process. Upon completion of each education module, the employees should promptly take a quiz. It is important that your medical organization deliver the results to the employees in a timely manner. If an employee does poorly on their quiz, a plan of action should be in place that would ensure they take the training and quiz again. All training supporting documentation, including the test results, should be kept in the employee's personnel file.

Per OIG compliance guidelines, all training material should take into account the skills, knowledge, and experience of the individual.

You can keep records of each individual's attendance at all training and education seminars, containing the outline and/or content of training. During annual audits these training records should be reviewed to ensure training requirements have been met. HR should, if possible, also keep a tickler file that has a spreadsheet listing all employees' names with training and education received. This provides HR with a quick snapshot of who is non-compliant and who needs follow-up.

When employees are hired, they are placed on a probationary period. Please keep in mind that it is not only the employee who is on probation; your medical organization is also on probation for the employee to determine whether or not it is a good fit for them as well. That's why it is important to have an effective orientation process.


Orientation is the prime time for a medical organization to showcase its mission and values, policies and procedures, benefits, employee expectations, and culture. An effective orientation process should be well-structured, organized, and include continuous employee follow-up. Probationary period timeframes typically state they will perform evaluations after 30-, 60- and 90-day periods. Best practice for orientation would be to ensure your new employee has received the following within the first three days of employment:
  • Benefits application and package;
  • Uniform order forms (if applicable);
  • Organization chart;
  • Tour of practice;
  • Policies and procedures (Employee Handbook);
  • Training schedule (with names of trainer(s);
  • Work schedule; and
  • Pay schedule (with holidays noted).

This is not an all-inclusive list; however, it lays a good footprint for ensuring the orientation starts off right.

After the first week, the new employee should have a meeting with their supervisor to see how the first week went and answer any questions the employee may have at that time. The employee should receive an evaluation by their trainers, peers, and supervisor at 30-, 60-, and 90-day intervals. This will give the supervisor plenty of time to determine whether or not the probation period will be extended, and whether the employee will stay or be dismissed.

If the supervisor determines that the employee will stay and they accept, then at this point your new employee has been successfully trained on his or her position, knows their job roles and responsibilities, knows the culture of the medical organization, and knows they will be held accountable for not meeting the expectations of his or her employer.

Regardless of whether you are an independent practice, billing company, medical organization, or other third party, your HR department is a vital department. It could be extremely costly to your medical organization if it is not run properly. Make sure the employees hired within your HR department are knowledgeable and up-to-date with compliance program requirements. Also ensure that there are consistent and timely meetings between your HR and compliance departments. All of these meetings should have meeting minutes taken and brief summaries provided to all attendees for future reference. This will lessen any communication gaps and build a more efficient medical organization. It will also keep employees engaged and less likely to leave due to any frustrations they may have regarding their medical organization's culture. Employees will appreciate the continuous training and education, and will be more confident when performing their daily duties. There are many studies that indicate employees remain more engaged with their employer when the employer shows them they care; show your employees you care by selecting the right candidates, providing job descriptions, policies and procedures or an employee handbook, and keeping your employees in the know.

The only constant in healthcare is change. There are continuous changes to federal regulations, and many practices or medical organizations get caught up in their daily operations and forget about the compliance component of their business, as well as how compliance interrelates with the HR department. Don't let the government knocking on your door be a shocking reminder.

Michelle Ann Richards, CPC, CPCO, CPMA, CPPM, has 26 years of healthcare experience, which includes being a subject matter expert on practice management, HR, coding, compliance, and quality improvement. She holds a Bachelor of Science in healthcare administration. She is the director of engagement, compliance services for AAPC's compliance division called Healthicity. She has also owned her own business called Coding & Compliance Experts since 2009.










Related Searches: HR, Compliance, Compliance Program, Human Resources