Kusserow on Compliance: A definition of health care compliance

A good starting point for meeting the obligations of a compliance officer’s position is to define health care compliance. This can be useful in developing plans and objectives for the program, as well as explaining the meaning to executive leadership and the board.

  1. Health care compliance is defined as adhering to laws, rules, regulations, and program requirements, as well as the Codes of Conduct, policies, and procedures for the organization. Meeting this definition means identifying and meeting all applicable legal, regulatory, program requirements, and payment standards that vary considerably depending on type of organizations and the services they provide. To achieve this requires promoting not only compliance with rules, but ethical conduct and a culture that promotes prevention, detection, and resolution of conduct that does not conform to the established rules.
  2. Health care compliance can also be defined also as the ongoing process of meeting, or exceeding the legal, ethical, and professional standards applicable to a particular health care organization or provider. The HSS Office of Inspector General (OIG) has helped with the definition of health care compliance through its compliance guidance documents, which call for compliance efforts to be designed to establish a culture within organizations that promotes prevention, detection, and resolution of instances of conduct that do not conform to federal and state law; federal, state, and private payor health care program requirements; and ethical and business policies. The scope extends to many areas including patient care, billing, reimbursement, managed care contracting, research standards, Occupational Safety and Health Administration (OSHA) standards, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, and the Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules, to name a few. The biggest challenge for health care organizations and their compliance officers is keeping track of all these numerous requirements and regulations.

Meeting the definition for health care compliance means meeting all of the rules and requirements set forth and applicable to them across a broad range of criteria, including all applicable legal, regulatory, program requirements, and payment standards that vary considerably depending on type of organizations and the services they provide.  As one examines the meaning of health care compliance, it becomes clear that it embraces a great variety of things, including adhering to laws, rules, regulations, and program requirements, as well as organization Codes of Conduct, policies, and procedures governing the day to day operations. Because health care has become so complex in recent years, the industry is under constant scrutiny. Compliance programs promote not only compliance to rules, but to ethical conduct and the promotion of a culture that encourages prevention, detection, and resolution of conduct that does not conform to federal and state law; federal, state, and private payor health care program requirements; and the organization’s ethical and business policies. It is nearly impossible to define the extent or complexity of the ever changing healthcare compliance world. New laws and regulations come into play on a daily basis from all level of government.  Some of these have far ranging implications such as HIPAA and HITECH laws that are designed to protect the privacy of patient information.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2018 Strategic Management Services, LLC. Published with permission.