The Seven Elements of the HHS OIG Compliance Program


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The Department of Health and Human Services (HHS) Office of the Inspector General (OIG) have created a program that can ensure that healthcare compliance is enforced throughout the nation. The reason for this is that statistics and audits proved that medicare lost more than $20 billion in 1996.Reflecting on the current economic slump, the money, which was lost because of fraud, waste and error, would have been helpful today.

However, the past is long and gone. The future lies in implementing healthcare compliance. For this program, seven guidelines are required, and those are:

1) Implementing written policies, procedures and standards of conduct that promote the healthcare facility’s commitment to compliance and address specific areas of potential fraud and abuse.

The first part of this element, i.e. written policies, procedures and standards of conduct, aims at reducing risks such as cost reporting and inducements. This indicates that policies and procedures should be complete and accurate. As for fraud prevention, this protects the facility and its patients from fraudulent persons.

2) Designation of a compliance officer and compliance committee charged with the responsibility for developing, operating and monitoring the compliance program, and who reports directly to the owners, governing body, and/or CEO.

Like any compliance rule, this program requires that a dedicated professional or a group of people work on ensuring that it is enforced. Plus, having an accountable body ensures everyone at the facility that the best practices outlined by the program will be implemented properly.

3) Development and implementation of regular, effective education and training programs for all affected employees.

Training sessions are very useful for employees because they teach them numerous best practices such as how to comply with medicare requirements, how to document clinical and financial records properly and efficiently, and other important aspects healthcare professionals should know of.

4) The creation and maintenance of an effective line of communication between the compliance officer and all employees, including a process such as a hotline or other reporting system to receive complaints, and the adoption of procedures to protect the anonymity of complaints and to protect whistle blowers from retaliation.

In most cases, people who welcome healthcare compliance are bullied by their opponents in order to hide their mistakes. However, with this element implemented, reporting those who don’t comply is much easier and more effective. As a result, compliance rules will be enforced better.

5) The development of policies and procedures addressing the non-employment or retention of excluded individuals or entities and the enforcement of appropriate disciplinary action against employees or contractors who have violated corporate or compliance policies and procedures, applicable statutes, regulations, or federal, state, or private payer healthcare program requirements.

6) T he use of audits and/or other risk evaluation techniques to monitor compliance, identify problem areas, and assist in the reduction of identified problems.

The program should be put through ongoing evaluation to ensure that it is effective in complying with the rules and regulations established. Reviews like testing employees for knowledge of requirements and employee surveys are very important to gauge the success of the program.

7) Violations of a facility’s compliance program policies threaten the facility’s reputation as a reliable, honest, and trustworthy health-care provider.

Facilities enforcing the compliance program should act on problems once detected to reduce their chances of criminal prosecution and penalties.

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