Developing An Effective Healthcare Compliance Program

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Why must every health care entity have an effective compliance program?

Because a health care compliance program demonstrates to employees and the community that the organization is committed to honesty, ethical behavior and acting responsibly.

It encourages employees to report problems, and it creates a process by which the organization can identify and prevent criminal and unethical conduct.

It can also help to identify and correct compliance problems — such as Anti-Kickback Statute and Stark Law violations — before they are discovered by the government or reported by a whistleblower.

More importantly, without an effective compliance program in place, if health care fraud is identified within your health care entity, your culpability can be increased. This can lead to allegations of deliberate ignorance and subsequent investigations.

At Chapman Law Group, our health care compliance consulting lawyers can advise your practice on how to stay in compliance with state and federal healthcare regulations and the best practices to follow.

What an Effective Compliance Program Entails

health care compliance attorneysAn effective compliance program is a proactive measure. It can reduce fines and penalties resulting from health care fraud investigations and prosecutions, by reducing the organization’s culpability score.

The U.S. Sentencing Guidelines provide for reduced criminal fines and penalties for organizations, including health care organizations, that have implemented a compliance program prior to the offense.

The Office of the Inspector General (OIG), for example, will consider the existence of an effective compliance program that pre-dated any governmental investigation when addressing the appropriateness of administrative penalties.

Further, the False Claims Act provides that a person who has violated the FCA, but who voluntarily discloses the violation to the government, in certain circumstances will be subject to double, as opposed to treble, damages (see 31 USC 3729(a)).

Moreover, an effective compliance program can actually prevent investigations and qui tam cases in the first place. By identifying and correcting improper payments, responding to a hotline and other complaints, and monitoring and self-auditing compliance with program requirements, an organization may prevent an investigation from ever happening.

The government also takes into account whether a health care provider has an effective compliance program in place when deciding to prosecute or impose penalties (USAM 9-28.800).

Monitoring and auditing under a compliance program are essential to complying with federal overpayment or “reverse false claims” requirements, and to identify and self-report any violations of law or CMPs before an investigation begins. By returning overpayments on a timely basis and self-reporting violations, an organization can significantly reduce CMPs and other penalties.

An Effective Compliance Program Must Include All Seven Elements Found in the Sentencing Guidelines:

      • Written policies and standards of conduct.
      • Compliance officer and compliance committee.
      • Effective training and education.
      • Effective lines of communication and hotlines.
      • Enforcement through disciplinary actions.
      • Monitoring and auditing.
      • Prompt response and corrective action.

The HHS-OIG has published Compliance Program Guidance for a number of health care industries, including hospitals, physicians, nursing facilities, hospices, home health agencies, clinical laboratories, durable medical equipment suppliers, and Medicare Advantage organizations.

The HHS-OIG guidance should be carefully reviewed and used in developing a compliance program. If no guidance exists for your industry type, consult the guidelines for similar provider types.

Let Our National Healthcare Lawyers at Chapman Law Group Help Develop an Effective Compliance Program for Your Practice

The health care compliance attorneys at Chapman Law Group have 35 years’ experience in state and federal health care regulations and best practices across the U.S. One of our lawyers has worked as a Medicare attorney, another is an ex-Medicaid fraud prosecutor, and each of us holds an LL.M. in Health Law from Loyola University Chicago School of Law, the top school in the United States for healthcare law.

Our lawyers analyze policies and procedures, to ensure that licensed healthcare providers avoid criminal and civil liabilities for False Claims Act, Anti-Kickback and Stark Law violations — and we defend providers who face related charges.

Chapman Law Group has four national offices: Detroit, Michigan; Miami and Sarasota, Florida; and Los Angeles/Southern California.

Let our national Medicare audit lawyers and Anti-Kickback Statute and Stark Law defense attorneys put a solid health care compliance reporting strategy in place for you. Contact us today.

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