Elements of an Effective Compliance Program
The Office of Inspector General of the Department of Health and Human Services (OIG-HHS) was founded in 1976 to fight fraud, waste and abuse in Medicare, Medicaid and more than 100 other HHS programs. To give medical practices guidance, promote the prevention of criminal conduct, and enforce government rules and regulations, OIG-HHS introduced the Elements of an Effective Compliance Program. Section 6401 of the Patient Protection and Affordable Care Act took this one step further, making a compliance program a mandatory condition of enrollment in Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).
The development of this framework was based on the belief that a health care provider can use internal controls to monitor adherence to applicable statutes, regulations, and program requirements. These elements act as a first line of defense; identifying and correcting potential discrepancies in billing, reducing the chance of fraud and abuse, and promoting quality care.
“Just as immunizations are given to patients to prevent them from becoming ill, physician practices may view the implementation of a voluntary compliance program as comparable to a form of preventive medicine for the practice.” 65 C.F.R. 194, 59444 (Oct. 5, 2020).
These seven elements are discussed below.
For any questions contact Ardag Hajinazarian, Rush Health and Rush Health ACO Compliance Official.
Office of Inspector General (OIG) and Department of Justice (DOJ) have suggested, “…compliance programs are the most important step a provider can take to minimize regulatory risks”