Since the HHS Office of Inspector General (OIG) released its General Compliance Program Guidance (GCPG) in November, the compliance professionals at UofL Health in Kentucky—like their brethren elsewhere—have been comparing the seven elements of their program to OIG’s best practices.[1] Sometimes, UofL’s compliance professionals were relieved to find they’re on the same page as OIG, which was the case with employee access to policies and procedures. Other times, they found areas for improvement, such as certain policies and procedures that could use more detail.
Either way, “this is an opportunity to benchmark your compliance program and make sure you’re meeting these expectations as best as you can,” said Shelly Denham, chief compliance officer at UofL Health. For their gap analysis, Denham and her compliance team put together a spreadsheet of the GCPG’s seven elements (see below). The GCPG was also the impetus for another health system’s decision to revise its governance structure.
Like other compliance professionals, Denham has also been focused on OIG’s stating that “entities should incorporate quality and patient safety oversight into their compliance programs.” UofL Health has a vice president of quality and patient safety, and while compliance follows its metrics and reporting requirements, the two departments operate independently. “We will be having conversations to see what we can do to add to our compliance program and support those efforts and demonstrate that partnership,” Denham said.
In terms of the gap analysis, Denham and her compliance team reviewed UofL’s policy inventory, with an emphasis on common compliance risk areas, such as coding, billing, marketing, quality of care and physician arrangements. They identified opportunities to shore up certain policies, which is part of the first element of a compliance program. For example, compliance specialists plan to make the physician contracting policy more specific in terms of the process its lawyers use for managing contracts. “It’s also important we specify that we look at fair-market value and how we do it,” she noted. The marketing policy, which is about interactions between marketing liaisons and physicians, also will be updated, with more guidance for liaisons and examples to help them distinguish between appropriate and inappropriate conduct.
More broadly, the GCPG states that “All relevant individuals should be able to easily access their organization’s code, policies, and procedures,” and it “should be comprehensible by all relevant individuals (e.g., translated into other languages, where appropriate, and written at appropriate reading levels).”
