HEALTHCARE COMPLIANCE 2 – Healthcare Compliance Program For Hospitals (HEALTH INFORMATION MANAGEMENT) Information Systems homework help

  1. Hospitals are subject to the same law as healthcare organizations. Aspects of these laws and statues create compliance obligations that are unique to hospitals, list and explain four of these unique obligations. 
  2. What technique is similar to audits? What does it entail?

(there is no word limit)

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


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


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

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