Kusserow on Compliance: Documentary pillars supporting effective compliance programs

16 key documents described

Critical to an effective Compliance Program (CP) is reinforcing it with key documents that provide the supporting pillars. The following describes some of most important compliance program documents:

  1. Code of Conduct. This can be viewed as the Constitution for the organization and should be distributed to all covered persons.
  2. Charters for the Executive and Board Level Oversight Committees. These should establish oversight and support for the CP and define roles and responsibilities.
  3. Compliance Officer Charter/Position Description. It is important to formally describe the role of this position, responsibilities, reporting relationship to the CEO and Board, etc.
  4. Protocols Between the Compliance Office and Legal Counsel, HR, Internal Audit, etc. Many functions overlap or intersect with the Compliance Office. Working relationships need to be defined to avoid “turf issues.”
  5. Compliance Education and Training Policy. This should describe the development and implementation of regular, effective education and training programs for all affected parties, and describe general topics covered, frequency of training, and how you will document completion of the training.
  6. Hotline Charter/Policy. There needs to be a document that establishes a process to receive complaints and how they will be handled. It should describe how individuals can report concerns and ask questions or request guidance.
  7. Policies Addressing Ongoing Monitoring of High-Risk Areas. This is for program managers on their responsibilities to monitor their risk areas, develop and implement written guidance to their staff, training of the staff on how to comply and verify they are following the instructions properly.
  8. Policies Addressing Ongoing Auditing of High-Risk Area. These should address independent reviews of high-risk areas to verify and validate ongoing monitoring is operating the way it should and assist in the reduction of identified problem areas.
  9. Policies Governing Internal Investigations. Outline of the general steps that will be taken to investigate a report of possible problems; and documentation of results.
  10. Policies Addressing Non-Engagement of Sanctioned Individuals and Entities. This should state that there will be no engaging, contracting with, accepting referrals or prescriptions from those that are sanctioned, excluded or debarred from federal and state health care programs.
  11. Conflicts of Interest Policy. This should require all potential conflicts of interest be disclosed and provide a method for addressing them.
  12. Anonymity and Confidentiality Report Policies. Employees should be allowed to report potential wrongdoing anonymously and policy should protect the identity of those who request confidentiality.
  13. Non-Retaliation Policy. This should address protection against retaliation of those reporting potential wrongdoing.
  14. Document Policy Management and Retention. This should outline document retention and destruction requirements and should address electronically maintained documents.
  15. Credentialing and License Policy. This should address which individuals must maintain licensure and state that make clear no engagement or contract individuals and entities that are not properly licensed. It should define verification procedures.
  16. Disclosure of Overpayments and Violations of Law and Regulations Polices. Overpayments are common and sometime there is identification of wrongdoing. Strict rules should govern when and under what circumstances disclosures to outside parties is required.

These are only a starting point. All policies should be reviewed on an annual basis and updated as necessary. This includes eliminating policies that are no longer appropriate or relevant and writing new ones. All policies should be written in a template that permits you to document when a policy was last reviewed and when it was last changed.

For more information on this topic contact Marvin Mills (mmills@complianceresource.com) at the Compliance Resource Center that maintains over 1,000 compliance-related policy templates.

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.

Connect with Richard Kusserow on LinkedIn.

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Copyright © 2020 Strategic Management Services, LLC. Published with permission.