Fourth Quarter Compliance Officer Initiatives
Register for complimentary CEU credited webinar “Building Blocks for Effective Compliance Programs (sai360.com)” November 10, 2022, at 2 PM Eastern
As the calendar year comes to an end, many Compliance Officers will begin planning their Annual State of the Compliance Program Report, defined as a report on the status of the organization’s compliance with applicable laws, regulations, and other standards, as well as any identified control weaknesses with compliance risk areas. This is one of the most important duties that a Compliance Officer performs. The audience may include executive leadership, board, and business partners. Another audience might be government regulators. Having such a report on hand can go a long way in mitigating enforcement actions. The report should not only include accomplishments but also planned initiatives for the upcoming year to improve and enhance the program.
For many Compliance Officers it has been a common practice to report process outputs with numerical results, such as the number of employees trained, individuals screened, hotline reports, new/revised policies, etc. This includes results from any internal checklist reviews. However, reports of these types alone sound hollow and lack credibility for executive leadership, boards, and outside authorities as to the outcome of all these process results. It is the resulting outcome that effectiveness is evidenced. Therefore, in the last quarter of the calendar year, it is worthwhile to consider ways to generate credible outcome evidence of the program’s progress and improvement and enhancement planned for 2023. The most credible information comes from independent sources that perform their work objectively.
Key elements of the report should evidence the status of the organization’s compliance with applicable laws, regulations, and standards; and what actions are needed to improve and enhance corporate compliance. The organization of the report should include:
- A summary and overview of the results of the annual review;
- The scope of what is included in the development of the report;
- Evidence of the results of compliance efforts (outcome of the process);
- Opportunities for program improvement; and
- Planned actions to enhance the program’s effectiveness.
There are several options to consider when deciding upon what type of information would be the most useful for the report, including the following:
- A Compliance Program Effectiveness Evaluation is the most credible evidence of the program’s progress but also identifies opportunities for improvement and enhancement.
- A Compliance Program Gap Analysis is a step-down cost-wise and in terms of qualitative results.
- Operational risk management audits, especially those highlighted by the Department of Health and Human Services Office of Inspector General (OIG). For example:
- Arrangements with referral sources is the highest Department of Justice and OIG enforcement priority;
- Claims processing system is the second highest enforcement risk area;
- Conflicts of interest at all levels of the organization; and
- EMTALA (for hospitals).
- Compliance Knowledge and Culture Surveys are the least costly outside reviews. They were cited by the OIG and the Health Care Compliance Association’s (HCCA) Roundtable Report, “Measuring Compliance Program Effectiveness: A Resource Guide,” 64 times as a means of evidencing effectiveness.
Regardless of the method used, the results should include actions for program enhancement. An action plan should be made part of the report in a summary presentation with the executive leadership and board.
Register for complimentary CEU credited webinar “Building Blocks for Effective Compliance Programs (sai360.com)” November 10, 2022, at 2 PM Eastern
Contact Richard Kusserow for more information on this topic at [email protected].
For Compliance FAQs go to www.compliance.com/faqs/
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