Assuring Good Health

When employees work under the roofs of a company or organization, the responsibility of keeping them fit and out of harm’s way is heavily tied to its policies and rules about safety. Safety instructions and proper training can help avoid costly and arduous visits to the doctor’s office.

Regular medical checkups of the company personnel will guarantee a disease free environment. A person infected with some radioactive element whilst working in a fission plant not only threatens the well being of other employees but also the well being of the plant itself. A sick employee will lead to more sick employees eventually slowing down the production process.

Health checkups before hiring an employee will also assure the positive advancement of a company as an unfit employee won’t be able to work with maximum efficiency. This will affect the overall production capacity as each and every individual has a part to play in the manufacturing process.

Making sure that the personnel working a particular plant abide by the safety standards set by the Health Care Compliance Association (HCCA) is a must for every organization.

Avoiding Scams

Healthcare compliance has become a source of extra income for some medical practitioners. The doctors’ offices issue unnecessary tests and medicine to patients from organizations or companies with huge insurance policies.  Selling a particular brand of medicine or equipment is part of being included in the profit.

Companies selling safety equipments and gears are also obliged to follow the rules set up by the government and international standards. The inability to abide by these rules can result in penalties like criminal charges in case of casualties that could have been easily averted.

Over the years, there have been constant repetitions in misrepresentation by medical technicians and doctors seeking their own gain. This has not only resulted in unwanted and surprised audits for companies, but in worsening of personnel health too.

Personnel with minor fitness issues like temporary blood pressure increase and UTIs have gotten far sicker because of conformity negligence. The unnecessary use of endoscopes or CT Scans has resulted in increased fitness risks among patients.

Since the use of a particular medication or machinery benefits the medical officer or technician, they instruct its usage without the need to fill up their pockets with a few extra bucks. Hence, the doctor patient confidentiality is taken advantage of in a brutal way.

This kind of unprofessional behavior not only risks a patient’s life but also puts the company or business’s credibility on the line with an audit from the Health Services Department. The law requires each and every company to be in line with the healthcare compliance guidelines provided by the government and the HCCA (Health Care Compliance Association).

The HCCA even has its own socializing website to help companies and personnel be aware of the lurking conformity dangers associated with medicine.

Organizations providing medical attention to working personnel have to go under scrutiny from the government to ensure that no misconduct occurs whilst giving medicinal care to patients. Since the patients belong to a company, it is targeted for auditing and investigation.

It is important to understand the risk ill employees attract for other coworkers. This meant that business institutions need to find ways of reducing this risk through risk management best practices. Reducing the prevalent risk factors is the best approach to ensure efficient risk management.

The most important requirement for managers is to make use of the knowledge of health risk and cost management. This will help employers establish target programs where health risk management should be implemented. At the same time, this knowledge will help to estimate cost saving that may result from the intervention. These best practices will prove effective in helping employees calculate the potential returns before investing.

A WHO report cited a research on economic benefits of healthcare programmes in the workplace. The study was conducted using data for an average of 3 to 6 years. According to this data, implementing healthcare insurance for employees reduced sick leaves by 27%. This subsequently reduced the costs associated with sick leaves by 26% because of best practices. Moreover, there was a reduction of 32% in workers claims to compensation and due to disabilities with effective risk management.

Components of Workplace Wellness Programmes

The success of workplace wellness programs depends on the following components:

• Health and productivity management programs must be integrated into basic operations of the organization.

• Take account of policy, individual, cultural and environmental factors that affect health and productivity at the workplace. Such issues must be addressed regularly for best practices.

• Target identified health issues in employees.

• Managers must be prepared to address needs of employees effectively and swiftly.

• High participation of employees in the organization.

• Conduct accurate evaluation of employees.

• Inform stakeholders about successful outcomes.

• Maintain accounts of health factors affecting employees.

• Handle presenteeism issues effectively and rigorously.

Managers who implement best practices look at those employees who are self sacrificing for the organization with favor. These are workers who come to work despite being ill because they are concerned about decreasing productivity. Tackling presenteeism is one of the major challenges in most business organizations.

Therefore, a major benefit of healthcare program at workplace is that sick leaves reduce and presenteeism improves. This strengthens risk management along with other important best practices.

Employee health symbolizes significant business risk. With proper risk management, a proper program for maintenance of employee health can help reduce risk. Usually companies ignore this common knowledge and face larger losses by spending on poor health of employees. Everyone knows that prevention is always better than cure. A proper wellness program as a best practice can save thousands by preventing serious illnesses in employees. The same will be applicable for those employees that are disabled.

Consider an example cited by Alain Peddle the head of Research and Development at Discovery Health. An employee has a health problem and due to financial restrains doesn’t get access to quality healthcare. Such an employee will incur losses to the company due to reduced work hours. Moreover, retaining an employee with health problems and disabilities requires spending more on to ensure compliance with best practice. There will be requirements to fulfill like; modification in transportation, assistance with movement and other changes to make them comfortable to work. If replacement is the option, then replacement of the staff will also incur additional expenses. This includes spending on recruitment through best practice.

A medical debate is still on about whether medical aid mitigates risk of losses due to employee illness. There are cases where an early intervention with medical care, as a best practice can benefit the company.  If the illness of an employee is ignored it can lead to decreased productivity. Often, employees look for loans from their employer to cover medical expenses. These loans can be as much as thousands of dollars and company takes the risk by lending money to their employee as a best practice.

Such a risk can be evaded by using the best practice of healthcare insurance. There are a range of options which work for different risk management profiles. Employees can choose what suites them best for healthcare coverage. The bottom line is that it is always a best practice to have all the employees enrolled with medical health insurance scheme. It saves companies from larger losses due to health issues with employees through healthcare risk management.

The risk factors associated with employee health are flexible. This is because most illnesses or diseases are preventable. However, this comes in handy only when companies have a strong system that identifies patients at risk and takes immediate treatment measures. For instance issues like high cholesterol, smoking, asthma, diabetes and others can be treated or controlled before they get out of hand. These can be controlled with counseling and improvement in lifestyle for best practice.

It is only right to conclude that implementing compliance with healthcare insurance is the ideal best practice required to mitigate risk of employees’ illness.

No More Denials or Expensive Premiums

Starting from 1st January 2014, adults will not be denied health coverage due to preceding conditions. This best practice in healthcare will not discriminate patients based on gender or gender specific treatments. This includes preceding conditions such as childbearing in women.

More Healthcare Insurance Providers

By 2014, families and individuals will have to acquire a minimum healthcare insurance level as a recommended best practice. To ensure compliance with this best practice, employers and other providers or contractors will be able to offer insurance at affordable rates. This will be possible through localized healthcare providers or contractors in every state. As a crucial best practice, there will be subsidies available for those who have limited incomes. Additionally, those people who do not opt for healthcare insurance will be fined for failure of compliance with an essential best practice.

More Coverage on Mental Health and Substance Abuse

Most health insurance organizations already include coverage for mental health and substance abuse. However, as a best practice, by 2014 compliance from individuals and small insurance organizations will also be required. This best practice will ensure extended insurance for people.

No More Annual Limits on Health Care Insurance

By 2012 as a best practice, insurers shall be expected to cover as much as $1.2 million worth of medical expenses. Following this best practice, in 2013 the amount will rise to $2 million. After this, in 2014 the expenses will be eliminated completely.

Coverage Extends To Low Income People

In 2014, there are best practices plans for individuals who earn less than $15,000 per annum and families depending on $29,000 per annum. Such people will be able to enroll with Medicaid, which is a federal public health insurance provider.

“Doughnut Hole” Ends

The Medicare Part D coverage gap is also known as the “Doughnut Hole”. This will come to an end in 2020.

These new best practices planned for the future are meant to improve access to healthcare insurance by almost everyone living in the United States. Compliance with these new regulations will only make healthcare status better than it has already been.

Therefore, it is an essential best practice to have a compliance plan. A compliance plan is a set of systematic procedures which have been introduced by the organization. These procedures are meant to comply with regulations imposed by the government as a best practice.

Coding component is an important feature of a compliance plan. It is an effective approach to preventing Federal fraud and abuse of investigations of healthcare claims. It requires healthcare providers to ensure compliance with regulatory laws appropriately.

Coding Practices: These are a set of best practices in which software applications are developed in a simplified manner. The software is broken down into many levels and codes are used to make it easy to keep track of every level. These are based on various features, like platform, target environment and coding language. Implementing best practices for specific situations greatly reduces the risk of errors regardless of the software development model being used.

To ensure this there are three specific coding compliance strategies which need to be implemented as best practices. These include:

• The 72 hour Cases: Coding components make billing procedures for outpatient diagnostic services occurring within 72 hours of patient admission quicker and effective.
• Billing Practices: Coding components ensure that billing is appropriate and not misused. That means consultations with resident doctors must not be wrongly entered as physician consultations.
• False Claims: There is need to ensure there is compliance with the False Claim Act. Using coding components makes it possible to monitor fraud at every sublevel. Additionally, false claims of patient transfers as discharges must be detected and investigated.

Reasons for Healthcare Facilities to Install a Coding Compliance Plan

Firstly, developing effective internal controls is an important best practice. A coding compliance plan ensures that effective internal controls are developed. This is a major requirement when it comes to ensuring compliance with the False Claims Act.

Secondly, there is need to identify problematic coding practices to ensure best practices. Therefore a comprehensive coding compliance plan is recommended for healthcare providers. This will help in identifying practices which are questionable. The provider can also take the initiative of submitting a voluntary disclosure to the government or remit the overpayment to the intermediary. This will minimize criminal or implicative actions against the provider.

Thirdly, using a compliance plan will not only help in identifying problematic data, it will also identify opportunities. That is to say, that the provider can get notified about under-coding and have the opportunity to correct the problem. More specifically, a provider may have the opportunity to legally claim high level service.

Lastly, if a healthcare provider has its own compliance plan, the government will not have to impose a mandatory plan of its own. For example, healthcare providers must have specific features such as requirements when interviewing an employee. There must be a counsel present.

Therefore, having a compliance plan with a coding component is a basic best practice for healthcare providers.

Some key purposes of guidance for Healthcare Compliance include the following:

Interpretation: There is need to interpret laws governing the Health and Safety at Work Act to help individuals understand the requirements based on specific guideline; like the EC Directives. Additionally, there are different laws surrounding medical procedures and entitlement to healthcare policies. There is the need to interpret these with clarity and simplicity to ensure patients appreciate their entitlements.

Compliance with laws: Most healthcare laws require compliance by both the patient and administrative staff. Professional medical officers are also bound by certain medical laws protecting the ethics of medicine. When these laws are abused by medical personnel there are risks of litigation which have detrimental consequences. Therefore directors and managers in healthcare facilities must have proper guidance on implementing compliance with laws to ensure best practices.

Technical Advice: Medical technology keeps advancing as cures for diseases keep improving and science keeps advancing. Therefore, there is need for proper guidance on use of technological machines and gadgets to ensure best practices. Both patients and medical personnel like doctors, nurses and laboratory scientists must be enlightened on use and misuse of technology. Abuse of the guidance can have serious consequences for the patients. This will ultimately lead to the healthcare facility’s liability to legal action.

Compliance with Approved Codes of Practice: There is need for guidance on what appropriate practice is and what is inappropriate. For example decision making when a patient needs chemotherapy and when it is not the last option requires guidance. There are a set of medical examinations which must be conducted before a patient can be exposed to radiations. Therefore, compliance with approved codes of practice in medical facilities is a very sensitive requirement.

There is always need for sufficient guidance to ensure healthcare compliance. Failure to ensure that there is enough guidance as a best practice can lead to legal action and loss of lives.

1.       Risks and errors associated with Radiation Therapy: The ECRI has made specific recommendations to encourage best practices by implementing healthcare compliance to avoid over doses and accidents during radiation therapy. Healthcare facilities are required to ensure the following:

• Proper installation of machines
• Training and support for users
• Maintenance
• Implementation of corrective actions
• Regular inspections
• Risk management by avoiding oversights

2.       Hazards of Alarm Systems: There are usually two cases, one in which alarms overwhelm people in the healthcare facility. On the other hand, there may not be enough alarm systems to help in ensuring best practices in healthcare. Therefore, there must be enough and working alarm systems to make things comfortable for both the patients and staff.

3.       Cross Contamination by Endoscopes: There must be contamination free use of endoscopes. There are numerous instances where misuse of endoscopes has lead to infections in recovering patients due to contaminated cross ventilation. The ECRI recommends compliance with proper handling and maintenance processes to ensure contamination free use of endoscopes.

4.       Risks and Hazards Associated with CT Scans: It has been reported that the high doses of radiation during CT (Computed Tomography) Scans can increase the risk of cancer in patients. Therefore ECRI recommends monitoring and auditing of high level radiations as a routine to ensure best practices and healthcare compliance. The staff must be properly trained to ensure minimized risks for both the patient and themselves.

5.       IT Limitations and Complications:  There may be loss of data or system failures due to IT limitations and complications. ECRI recommends convergence of medical technology and Health Information Technology (HIT) to minimize adverse effects like:

• Commission Errors
• Omissions and wrong entries
• Data analysis errors
• Incompatibility of software applications and systems

Compliance with this recommendation will improve project management and ensure risk management as best practice.

6.       Problems with Leur Connections: Misconnections or faulty connections of catheters and tubes during treatment procedures are very harmful for patients. This can lead to introduction of harmful gases and wrong liquids unintentionally which interfere with the treatment and cause other complications. Therefore, it is a recommendation by the ECRI to ensure best practices in maintenance of devices and leur connections. Looking out for healthcare worker fatigue which is a common cause of oversight is important to ensure risk management.

7.       Risks with the use of PCA: Over sedation of patients during the use of Patient Controlled Analgesic (PCA) pumps can be life threatening. Therefore the ECRI recommends implementation of effective psychological therapy and regular follow-ups as best practice.

8.       Injuries and accidents within the facility: There are frequent accidents involving misuse or abuse of needle sticks and sharp instruments in medical facilities. There is need to ensure compliance with healthcare protocols to discard and handle these instruments with care. They can be a source of risk and hazards for other patients and medical staff as well. As best practice regular assessment of programs overseeing the use and handling of medical equipment is recommended by the ECRI.

9.       Fires due to Surgery: After surveys it was established that in the U.S there are about 600 fires due to mishaps during surgery. Therefore an ECRI recommends implementation of preventive and management programs for risk management in healthcare facilities. There is also need to ensure proper training on oxygen delivery as best practice to avoid risk of fire in theaters.

10.   Crisis in Emergency Room: Failure of defibrillators for resuscitation is a common problem which requires maintenance and proper installations. The battery must be charged at all times and ready for use. For best practices healthcare facility managers must ensure compliance with instructions for maintenance and availability of necessary gadgets in the emergency room.

To conclude, it must be emphasized that to ensure best practices there is need for compliance with ECRI recommendations.

Assess Yourself

The first best practice is to keep a check on yourself. Assess whether you are doing everything right with healthcare compliance. There are three basic guidelines for self assessment:

• Identify your weak points. Healthcare organizations need to conduct regular inspections as a best practice. This helps to ensure that duties have been distributed accurately and people are efficient. Administration, and other workers included in the organization must ensure they follow instructions appropriately and attend to patients according to requirements.
• Regularly review the guidelines and reforms in the medical world. It is a best practice to stay updated with current changes and information related to latest medicines to treat people. If this is not done rightly, the risk of wrong treatments becomes higher which is bad for healthcare professionals and the patient.
• Assess yourself on whether you are complying with the instructions and rules implemented by the insurers running the health insurance schemes. It is an important best practice to protect the interest of the patient and ensure he/she gets services appropriately.

What leads to an Investigation?

Upon investigation you may discover that your healthcare compliance is lacking all or most of the following.

• Accepting whatever the insurance carrier offers with no query.
• Accepting your patient’s account for settlement because you are working with a third party liability carrier.
• You might be allowing the patient to keep an attorney to handle the third party liability claim and accept the settlement offered by the attorney.
• Working with a limited number of healthcare providers and professionals like physicians and surgeons.
• You do not read the Explanations of Benefits (EOBs) where the insurance carrier mentions the reasons for denial on their part.
• Ignoring peer reviewer reports containing allegations of malpractice.
• Discrediting affidavits containing alleged malpractices and reasons for denials.
• Refusing to act in response to denials or allegations made against your facility.

Saving Yourself

If these basic best practices are lacking, here is what you can do to save yourself:

• Involve knowledgeable people with proper know-how about medical and administrative laws to ensure healthcare compliance can be implemented correctly.
• Establish a strong healthcare compliance format for medical laws, procedures and administrative protocols.
• Set up a set of protocols to be followed at every stage where deficiencies have been identified or assumed to exist.
• Set up a strong and flawless auditing process to assess medical and billing issues.
• Ensure than there is a refund whenever you have defaulted in providing services to the satisfaction of the insurer or the insured.
• Provide a hotline service to receive and attend customer complaints and concerns.
• A Corporate Integrity Agreement between you and the investigator can save you from an investigation before you correct your weaknesses.

Healthcare compliance is an effective and highly recommended best practice to save yourself from fraud investigation.

Healthcare professionals are constantly on their feet helping citizens with treatments for one ailment or the other, accidents and giving birth. However, there are some risk management laws they need to abide by to ensure the best practice in their profession. Therefore there are healthcare compliance issues with could have negative consequences on healthcare providers if there is no compliance.

Throughout the Unites States there are healthcare compliance guidelines. These help healthcare providers with guidance on a framework for handling appointments, surgeries, billing, coding of treatments, referring, and managing health insurances. The database of the people entitled to receive healthcare is too large and people tend to take advantage of this. There have been various fraud cases at different levels due to failure to comply with best practices. Most lapses leading to fraud in healthcare are poor management of records, incorrect billing, missed entries and miscommunication.

Professionals in healthcare are also expected to comply with best practices in order to maintain adequate risk assessment, ethics of practice, referral laws and patient rights. Professionals in healthcare must be able to manage their patients in compliance with these regulations to maintain high standards and patient satisfaction. There must be proper documentation of the bills which must be accessible during audits. Additionally, healthcare compliance reduces the risk of maltreatment, malpractice and abuse of patient rights.

Measures taken to Reduce Fraud Risk:

In order to reduce the risk of fraud, certain healthcare reforms have been implemented in the United States. These include:

• The RAC, Recovery Audit Contractor program has been extended to Medicaid and Medicare programs.
• Incase of alleged fraud the HSS and State agencies will be authorized to suspend the Medicare and Medicaid payments to providers and suppliers. Suspension will last during the investigation of fraud and end upon clearing of doubts.
• There will be a CMP (Civil Monetary Penalty) of $50,000 for any fraudulent payment or record under the healthcare program.
• Each day the provider or supplier denies access of the HSS to conduct audits, evaluations or investigations about their best practices; they will be fined $15,000.
• The amendment to AKS (Anti-kickback Statue) says that the person involved in violating the healthcare compliance does not need to know the prohibition of specific actions. Additionally, the government is not required to prove the intent of the person or organization to commit the violation.
• The Stark Law now prohibits established hospitals from expanding their facilities as well ownership.

There is a SRDP (Self Referral Disclosure Protocol) allowing providers and suppliers to disclose actual or potential violations of the stark law. Upon self disclosure the penalty will be reduced.