Zana Simjanovski (zana.simjanovski@mclaren.org) is Process Excellence Revenue Cycle Analyst II at McLaren Health Care in Shelby Township, Michigan.
In the healthcare industry, compliance has always been a hot topic that is greatly scrutinized by regulators, peers, and society. The changing landscape and evolving technology have allowed individuals to test the waters of ethics and reach past boundaries in hopes for a lucrative return. A system is put in place to deter these types of behaviors; however, there are outliers that disrupt the foundation of an organization’s principal values. Those outliers can be recognized beforehand, and their actions deterred or prevented when a monitoring and auditing plan is in place.
To understand the purpose of monitoring and auditing, an organization must first establish a compliance program. There are general guidelines to follow and more specific guidelines for certain specialties within the healthcare industry, some voluntarily. For example, laboratories and home care agencies have their own guidance from the Office of the Inspector General (OIG). A compliance program should outline the principal guidelines and, in addition, have a plan in place for those healthcare sector guidelines.
Organizations set up compliance programs with the intent to have a basic system in place to avoid unethical and criminal activity. To be truly successful, that system needs to be audited and monitored regularly.
Guidance
Various compliance guidelines have been developed, mostly from top regulatory organizations such as the U.S. Sentencing Commission (USSC), OIG, The Joint Commission, and the Sarbanes-Oxley Act (SOX).
Specifically, the USSC includes monitoring and auditing among the principal components of a recommended compliance and ethics program.[1] The USSC established sentencing guidelines in 1991, which include punishment for crimes and incentives for organizations that detect and prevent crime. Of all organizational offenders, the largest category was fraud. Of those fraud offenders, 22.1% did not have a compliance program in place. Those offenders were ordered to develop a compliance and ethics program as part of the probationary period.[2]
The OIG is part of the Department of Health and Human Services. Its main role is to fight fraud and abuse in Medicare, Medicaid, and other HHS programs.[3] The OIG provides compliance guidelines that target specialty healthcare sectors’ voluntary compliance plans.
The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in healthcare.[4] The purpose of The Joint Commission is to assure healthcare organizations are providing the best quality of care and safety to patients. These standards can vary by sector and service. Organizations can voluntarily become accredited or credentialed.
The Sarbanes-Oxley Act was promulgated in 2002 to provide guidance to all businesses and their financial activity. SOX has 11 titles, however, the only sections pertaining to compliance are as follows: 302, 401, 404, 409, 802, and 906.[5]
