The Rise of Health Care Compliance Programs


The Patient Protection and Affordable Care Act (PPACA) requires health care providers to enroll in a federally mandated health care plan and to adopt a health care compliance plan. Section 6401 of PPACA states that health care providers must establish a compliance program that contains certain core elements as a condition of enrollment. 

Compliance programs became popular in the early 1990’s when professionals in the health care industry were in need of a strategic and systematic way for companies to deal with misconduct and fraudulent activity.  The purpose of these compliance programs was to serve as a “mitigating factor in sentencing.”  Essentially, it set in place standards for health care providers to follow, so that when misconduct was detected, penalties and reductions by the government could be justified, providing a level playing field for all in the industry. The Office of the Inspector General (OIG) began to require compliance programs in investigations of Medicare fraud, which sparked the voluntary adoption of compliance programs by more health care providers.

The PPACA of course now requires most providers to adopt such plans by 2012, however the core elements of requirement have not yet been defined by regulation and will be different for each type of provider. Therefore, health care providers currently without compliance plans are working to draft and implement programs reflective of old guidelines. 

This is because fraud enforcement has increased and compliance plans will help to reduce or even avoid penalties for violations. The OIG’s Work Plan indicates a greater need for compliance in areas such as claims accuracy and provider training, suggesting these as areas of increased focus in future plan guidelines. Although the regulations haven’t yet defined the future core elements for compliance plans, previously issued materials help providers prepare for what’s next.

In the past, the following elements were typical of acceptable compliance programs:

 compliance program help

  • Establishment of written compliance policies and procedures and distribution to employees.
  • Designation of a specific individual or individuals to monitor compliance like a compliance officer.
  • Commitment to conducting formal training and education programs.
  • Development of internal system for communication of suspected compliance violations.
  • Commitment to auditing and monitoring to evaluate compliance and identify potential problematic areas.
  • Maintenance of disciplinary policies, which are consistently enforced.
  • Development of process for investigation of suspected violations and reporting to the government and law enforcement authorities when necessary.

These elements should likely be helpful to providers without compliance programs in place, to use in drafting plans for the future, allowing for practices to be proactive about changes.  This will allow practices, hospitals and care providers to communicate their culture and standards of ethics to their staff and patients in addition to the ability to provide a sense of transparency into the standards of practice operations.

Comment