Regulatory Compliance in Healthcare: Averting Medicare and Medicaid Fraud

The Center for Medicare and Medicaid Services (CMS), together with U.S. Department of Health and Human Services (HHS), seems to be in the exclusive business of writing regulations. And every health care provider that accepts CMS funding must comply with all applicable regulations.

As CMS states in its “Small Entity Compliance Guides”: “The various guidance and procedure documents on this website number approximately 37,000, comprising over 7 million pages.” 

Additionally, each state has its own set of regulations, as do health insurance companies.

Of course, complying with theses regulations is just the beginning. Health care providers must also comply with:

• • Occupational Safety and Health Administration (OSHA) and state safety regulations
  • State board regulations relating to the delivery of health care
  • State licensing regulations (professional rules/regulations)
  • Facility regulations
  • Labor department rules
  • DEA rules

CMS has made an effort to communicate the details of each rule to health care providers through “small entity compliance guides.” There’s also the Medicare Learning Network, an online resource from CMS that breaks down Medicare policy into plain language, provides educational compliance information for Medicare fee-for-service providers; and offers a variety of training and educational materials.

But are those CMS resources enough? More to the point, do you have enough patience and know-how to understand them?