Chapter 15 Learning Objectives: Elements Of A Hospital Compl

Chapter 15learning Objectiveselements Of A Hospital Compliance Program

Chapter 15 learning Objectives Elements of a hospital compliance program High risk areas of hospital operations Hospital-wide Standards of Conduct Duties of the hospital Compliance Officer Conducting compliance training and education Open lines of communication Continuously monitor program operations Responses to possible compliance offenses Example of a hospital compliance plan Introduction The purpose of a compliance program is to promote adherence to Federal and State laws on fraud abuse, and the program requirements of public & private health plans. The Office of the Inspector General (OIG) in the federal Department of Health and Human Services (DHHS) has issued two guidances on the structure and focus of hospital compliance programs.

Compliance Risks Unique to Hospitals (I) Outpatient services rendered in connection with an inpatient stay Submission of claims for laboratory services Physicians at teaching hospitals Cost reports Recruitment of physicians to medical staff Attracting patient referrals to the hospital Admission and discharge policies Compliance Risks Unique to Hospitals (II) Supplemental payments Tax-exempt standards for non-profit hospitals Gain-sharing arrangements between a hospital and its physicians Antitrust implications of hospital decisions to merge with or acquire each other HIPAA Privacy and Security Rules Compliance Risks Unique to Hospitals (III) Legal implications of trend for hospitals to purchase physician practices, align strategic hospital goals with those of physician practices, and enter into hospital-physician collaborations in support of an accountable care organization (ACO) Compliance with EMTALA in the operation of hospital Emergency Departments Benefits of a Hospital Compliance Program (I) Identify & prevent criminal & unethical behavior Ensure false & inaccurate claims not submitted Facilitate employee reports of possible problems Facilitate investigations of alleged misconduct Initiate prompt & appropriate corrective action Reduce exposure to civil and criminal penalties 7 Benefits of a Hospital Compliance Program (II) Central source for information on fraud & abuse Accurate view of employee misconduct Identify weaknesses in systems and controls Improve quality & efficiency of care delivery Build hospital reputation for lawful & ethical behavior Elements of an OIG Recommended Hospital Compliance Program Standards of conduct, policies, and procedures Designation of compliance officer and committee Regular education and training programs Process to receive complains System to respond to complaints and enforce disciplinary action Audit and monitor compliance Investigation and correction of problems Written Policies and Procedures (I) The framework of the compliance program consists of written policies and procedures that identify the most critical risk areas in the hospital and prescribe how people should act in those areas.

Standards of Conduct Claims preparation and submission process Medical Necessity Anti-Kickback and Self Referral Liability Written Policies and Procedures (II) Bad Debts Credit Balances Record Retention Performance Management Compliance Officer (CO) and Compliance Committee (CC) CO is focal point for compliance activities throughout the organization Full-time, access to CEO and BOD, sufficient staff and resources, adequate authority Typical responsibilities CC supports the CO in implementing the compliance program Typical duties Compliance Training and Education Training in legal requirements and compliance program that addresses them. Directed to hospital’s managers, employees, & physicians.

Hours per year, condition of employment, documentation of training activities. Topics covered by the training. Standards for evaluating effectiveness. Open Lines of Communication Reporting suspected incidents of non-compliance Several independent reporting channels Protect confidentiality and prevent retaliation Criteria for evaluating the communications environment Auditing and Monitoring To identify non-compliance problems & maintain functionality/effectiveness of the compliance program Periodic audits by internal or external auditors Risk areas targeted by the audits Initial baseline audit followed by regular measures of variations from that standard Annual review of program activities Responding to Detected Offenses with Corrective Action Types of corrective action that may be called for when a violation is discovered Value of reporting violations to government agency Prevent destruction of evidence and documents Factors in assessing how well a hospital deals with detected offenses Disciplinary Action for Compliance Violations Disciplinary action for violation of laws and compliance policies & procedures Range of possible disciplinary actions Rigorously screen job candidates to avoid hiring potential violators – looking for recent convictions, debarments, and exclusions Review of Real-World Hospital Compliance Plans MD Anderson Cancer Center example in book Other examples on the internet Other examples from local hospitals How each example compares to the recommended practices described in this chapter.

Paper For Above instruction

The landscape of hospital compliance programs has become increasingly complex due to the multitude of federal and state regulations shaping healthcare operations. The primary objective of these programs is to ensure adherence to legal standards, prevent fraud and abuse, and promote ethical practices within hospital settings. The Office of the Inspector General (OIG) of the Department of Health and Human Services has issued comprehensive guidance emphasizing the critical elements that constitute an effective hospital compliance program. These elements include a robust framework of policies and procedures, designated compliance officers, continuous education, open communication channels, periodic audits, and disciplined responses to violations.

One of the foundational aspects of a hospital compliance program is the development of written policies and procedures. These documents serve as a blueprint that identifies high-risk areas—such as billing practices, claims submissions, and patient referrals—and prescribes standardized responses aligned with legal requirements. For example, policies surrounding claims preparation must ensure that submissions are accurate, medically necessary, and compliant with anti-kickback statutes to prevent liability. Establishing clear Standards of Conduct further delineates expected behaviors for all hospital personnel, including roles related to medical necessity, record keeping, and ethical interactions with physicians and vendors.

The designation of a compliance officer and committee is vital for effective oversight. The Compliance Officer acts as the central point of contact, responsible for managing the day-to-day activities, while the compliance committee supports strategic decision-making. Both roles require sufficient authority and resources, with direct access to executive leadership. Responsibilities encompass implementing policies, conducting training, overseeing audits, and investigating suspected violations. Regular education tailored to hospital staff, physicians, and management reinforces awareness of legal obligations and fosters an ethical culture.

Open lines of communication are crucial to facilitate reporting of concerns without fear of retaliation. Hospitals establish multiple independent channels such as hotlines, anonymous reporting systems, and direct communication with compliance personnel. Effective communication is assessed through criteria like confidentiality, responsiveness, and the hospital's action in addressing reported issues. By promoting transparency, hospitals encourage early detection and resolution of potential violations, thereby reducing organizational risk.

Auditing and monitoring are essential tools for maintaining compliance and proactively identifying problems. Baseline audits establish performance benchmarks, with ongoing assessments tracking deviations over time. Regular internal and external audits target specific risk areas, including billing errors and improper physician relationships. Data collected informs corrective measures and enhances system controls. When violations are detected, hospitals respond with corrective actions, which may include disciplinary measures, retraining, or process modifications. Prompt, consistent responses help deter future violations and demonstrate accountability.

Disciplinary actions are an integral component of enforcement. They range from counseling and retraining to termination and referral for legal prosecution, depending on the severity of the violation. Hospitals rigorously screen prospective employees, reviewing criminal backgrounds and exclusions, to prevent hiring individuals with known violations. Additionally, examining real-world hospital compliance plans, like the example from MD Anderson Cancer Center, provides practical insights into how these policies are operationalized. Comparing these with recommended practices highlights the importance of adaptability and continuous improvement in compliance strategies.

Overall, effective hospital compliance programs are dynamic, multifaceted systems designed to foster legal and ethical integrity. They require committed leadership, thorough training, vigilant monitoring, and a culture of transparency. As healthcare regulations continue to evolve, so too must compliance efforts, ensuring hospitals can deliver high-quality care within the boundaries of law and ethics while safeguarding organizational reputation and financial stability.

References

• Office of Inspector General. (2022). Compliance Program Guidance for Hospitals. U.S. Department of Health and Human Services.
• Gostin, L. O., & Hodge, J. G. (2019). US Healthcare Law. University of California Press.
• Chung, S., & Beitsch, R. (2020). Hospital Compliance and Legal Issues. Journal of Healthcare Law & Policy, 23(4), 145-162.
• Roberts, R., & Travis, D. (2018). Ethics and Compliance in Healthcare. Medical Ethics Journal, 45(9), 21-29.
• HHS Office of Inspector General. (2021). Healthcare Fraud Prevention & Enforcement Action Team (HEAT). U.S. Department of Health & Human Services.
• Shaw, S., & Hudgins, M. (2020). Managing Healthcare Compliance Programs. Harvard Healthcare Review, 12(3), 67-75.
• American Hospital Association. (2023). Elements of Effective Hospital Compliance Program. AHA Publications.
• Sinclair, C., & Mullan, K. (2019). Legal Compliance in Healthcare Settings. Law and Health Journal, 33(2), 99-115.
• Brumfield, T. (2021). Strategies for Hospital Compliance Success. Healthcare Management Review, 46(7), 332-340.
• National Law Review. (2022). Best Practices in Healthcare Compliance Programs. Retrieved from https://www.natlawreview.com.