16 Tips in Code Development and Revisions
Register for a complimentary CEU credited webinar “Building Blocks for Effective Compliance Programs (sai360.com),” November 10, 2022, at 2 PM Eastern. The Compliance Certification Board (CCB)® has approved this event for up to 1.2 Live CCB CEUs each based on a 50-minute hour, each. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this event content or of the event sponsor.
Codes are a foundation stone for effective compliance programs
The Code of Conduct (Code) is a key foundational document for any effective compliance program. It should be an organization’s statement of guiding principles that is periodically reviewed and kept up to date. Compliance guidance from the DHHS OIG, the United States Sentencing Commission, DOJ, and other regulatory and enforcement agencies all underscore the importance and value of a proper Code. The Code should represent the vision, mission, and values of an organization and provide guidance for employee behavior that is consistent with and reinforcing of these values. A properly developed Code can offset pressures for engaging in unwanted conduct by informing employees about acceptable behavior the company expects and the conduct that will not be tolerated. A well written Code can provide a roadmap for compliance, demonstrate an organization’s commitment to compliance, and provide guidance as to expected behavior for individuals at all levels of the organization. The following are tips, considerations, and suggestions related to Code development or revision:
- It should be considered analogous to a Constitution that provides basic guiding principles, with policies acting like laws and regulations for more detailed compliance guidance.
- Work to create a document understandable by all (avoid exceeding high school reading level).
- Gain top-down buy-in, involvement, review and approval at Board and executive levels.
- Have CEO Code-supporting cover letter, as part of promoting a “culture of compliance”
- Determine responsibility for Code development, review, and revision. Most organizations leave it to the Compliance Officer to lead in this effort supported by a cross-section from various operational areas.
- It is important to gain wide buy-in for the Code. It is advisable to form a committee consisting of a cross-section of individuals. Their views and input go a long way in selling the Code to the entire workforce.
- Develop a plan for development with timeframes for step completion and the respective roles for everyone involved in the process.
- Decide upon size, formatting, and any inserts to be included in the Code. Generally, it should be 20 pages or less.
- A good practice is to introduce each section in the Code with a statement of guiding principle, followed by bullet point standards in furtherance of that statement.
- Organize the Code to address all stakeholders including, patients, employees, management, business partners, regulatory authorities, etc.
- Include a description of the Compliance Program and how to contact the Compliance Office via phone and e-mail.
- Address in general terms, regulatory and legal issues (e.g., fraud statutes, Anti-Kickback Statute, Stark Laws, etc.) that may impact the organization.
- The Code should make clear that everyone has an affirmative duty to report suspected wrongdoing, along how a report can be made, both in confidence or anonymously without fear of retribution or retaliation.
- Decide on the manner by which the Code will be disseminated and how covered persons may access it, such as having a hard copy provided as part of new employee orientation and posting it on the Intranet.
- Cross-reference policies and procedures against the Code to ensure there is no confusion or conflicts.
- Include an attestation form evidencing Code receipt, that they have read it, and will comply with its guidance. Such forms should be kept on file.
For more information, see Compliance FAQs at www.compliance.faqs/
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Register for a complimentary CEU credited webinar “Building Blocks for Effective Compliance Programs (sai360.com),” November 10, 2022, at 2 PM Eastern. The Compliance Certification Board (CCB)® has approved this event for up to 1.2 Live CCB CEUs each based on a 50-minute hour, each. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this event content or of the event sponsor.
