MD - Health Care Compliance Association

JOSEPH M. WATT
■ Solicit staff and employees’ impressions
using questionnaires
■ Review medical and financial records and
other source documents
■ Review written materials and documentation
prepared by the hospital
■ Analyze trends
Despite the 1998 guidance, many hospitals
have yet to perform periodic compliance effectiveness
reviews. Consequently, the OIG published
supplemental compliance guidance for
hospitals in the January 31, 2005, Federal
Register. In it, the OIG states there must be a
commitment to active involvement of organizational
leadership for every compliance program.
The OIG expects a hospital’s leadership
to promote a culture of values and rewards for
prevention, detection, and resolution of compliance
problems. Hospitals are expected to
develop a culture that values compliance from
the top down and fosters compliance from the
bottom up. The OIG believes such an organizational
culture is the foundation of an effective
compliance program. The OIG recommends
compliance program effectiveness be
evaluated based on outcome indicators such as
monitoring and evaluating billing and coding
error rates and identifying overpayments.
In addition to evaluating outcome indicators,
the OIG recommends hospitals evaluate the
seven elements through probing questions,
including, but not limited to, the following:
1. Compliance officer and committee
■ Does the compliance department have a
clear, well-crafted mission
■ Is the compliance department properly
organized
■ Does the compliance department have
sufficient resources
■ Is there an active compliance committee,
comprised of trained representatives
from each of the relevant functioning
departments
■ Does the compliance officer have direct
access to the governing body, CEO and
legal counsel
■ Does the compliance officer have a good
working relationship with other key
operational areas
■ Does the compliance officer make regular
reports to the board of directors and senior
management
2. Development of compliance polices
and procedures
■ Are policies and procedures clearly written
■ Does the hospital monitor compliance
with internal policies and procedures
■ Have the standards of conduct been distributed
to all members of the board of
directors, officers, managers, employees,
contractors, medical and clinical staff
■ Has the hospital developed and implemented
a risk assessment tool
■ Does the risk assessment tool include an
evaluation of federal health care program
requirements
3. Open lines of communication
■ Has the hospital promoted a culture
encouraging open communication without
fear of retribution
■ Has the hospital established an anonymous
hotline or similar reporting mechanism
■ Is the hotline or other reporting mechanism
well publicized
■ Are all instances of potential fraud and
abuse investigated
■ Are results of the investigation shared
with the governing body and relevant
departments
4. Appropriate training and education
■ Does the hospital provide qualified
trainers
■ Does the hospital conduct annual
compliance training
■ Is the training both general in nature and
specific to pertinent staff responsibilities
■ Does the hospital evaluate the contents of
its education program annually
■ Has the hospital kept current with
changes in federal health care program
requirements
■ Does the hospital seek feedback after each
training session to identify strengths and
weaknesses of the compliance program
■ Does the hospital administer post-training
tests
■ Has the hospital’s governing body been
provided with appropriate training
■ Has the hospital properly documented
who has completed the training
5. Internal monitoring and auditing
■ Is the audit work plan reevaluated annually
■ Does the work plan address the appropriate
levels of concern
■ Does the work plan include an assessment
of billing systems
■ Is the role of the auditors clearly
established and are coding and auditing
personnel independent and qualified
■ Has the hospital evaluated the error rates
identified in the annual audits
■ Does the audit include a review of all
billing documentation, including clinical
documentation
Continued on page 40
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
January 2006
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