Developing An Effective Healthcare Compliance Program

An 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.