Compliance Programs Are Not Cost Centers

Effective Programs Can Lower Costs, Increase Productivity & Improve Patient Care

The DOJ, OIG, United States Sentencing Commission, and new provisions of the Affordable Care Act are driving organizations to implement effective compliance programs. Compliance officers constantly struggle to sell the compliance program as more than another administrative cost center driven by an increasing number of regulations that affect business practices and health care delivery. The challenge is to focus on the benefits of an effective compliance program, and make the case that (1) the benefits far outweigh the initial costs of supporting the program; and (2) the program will save money in the long run. In reality, an effective program can truly contribute positively to the overall efficiency of an organization’s operations.

Potential Compliance Program Benefits

Guard against liabilities for non-compliance. This falls under the category of an ounce of prevention being worth a pound of cure. The DOJ, OIG, CMS, OCR, and other federal and state agencies are increasing their enforcement efforts, and compliance audits and investigations are increasing in number and scope. Recent enforcement actions have resulted in escalating fines and penalties. In addition, costly OIG Corporate Integrity Agreements (CIAs) contain mandated terms and conditions, including compliance program standards. Independent Review Organizations (IROs) and Compliance Experts must be engaged to monitor compliance with CIAs. In addition, CIAs require certifications for executives, program managers, compliance officers, and Board members. Even further, OCR has been increasing audits and penalty imposition. Effective compliance programs should reduce the risk of such liabilities by ensuring there are proper safeguards in place for all high risks facing an organization, including ongoing monitoring and auditing of these areas. If done properly, the organization is far less likely to encounter extraordinary expenses that are unrelated to the core purpose of providing quality care and avoid costly and time-consuming audits and investigations.

Reduce costly error rates in claims processing. One of the most significant expenses for an organization is dealing with error rates in claims processing. Correcting errors and resubmitting them takes time and resources. Weaknesses in this area expose the organization to a variety of outside authorities including CMS contractors (e.g., RACs or ZPICs), OIG auditors, and fraud and abuse investigations by federal and state agencies. An effective compliance program will ensure the existence of a quality assurance program in claims processing that includes quality control reviews (i.e., sampling live claims) to identify errors before submitting a payment. This should include tracking the source of errors and taking corrective action measures to address them, such as retraining. Program managers should be responsible for monitoring effort, but the ongoing testing of this activity to verify it is working properly and effectively should be part of ongoing compliance auditing. An effective compliance program will focus on this particular risk area to ensure the program managers are remaining current with changes in regulations and payment rules.

Raise workplace morale to increase productivity. It is important to create avenues for compliance communication with employees to detect and address concerns, suspected violations of law, regulations, the Code of Conduct, or policies. There are a number of compliance communication channels, but a hotline is the one most people think of first. However, the OIG has encouraged a variety of such channels, including surveying employees on their compliance knowledge, perceptions, and attitudes; and using compliance training as an opportunity to gain feedback from employees. Training sessions also need to explain to employees and medical staff what common compliance issues are, and how to report them and seek resolution. Actively having and supporting such a compliance program not only allows for addressing emerging problems before they become a liability, but also raises employee morale. It sends a message that the organization is committed to doing the right thing and that what employees think is important to management. All studies have shown that where morale rises, so does productivity.

Improve patient care and outcomes. Studies confirm that happy caregivers do a better job with patients and improve outcomes. This can be a real challenge in the stress-driven health care service arena. If the message from management is consistent with the focus on quality of care, it will translate to better care. If, on the other hand, the message is on bottom-line issues, it will not translate to better service and results. Sending the right message begins with an initial orientation, and continues through ongoing education and training programs. Addressing compliance concerns that regularly impact employees will lead to better outcomes.

Connect With a Compliance Expert

Strategic Management has decades of experience developing various compliance programs. If you are looking to implement a new program, or need someone to review a current one, contact us online or give us a call at (703) 683-9600 to speak to a compliance expert today.