Corporate Compliance

Assessing your compliance program

Compliance Monitor, April 19, 2006

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Assessing the effectiveness of your organization's compliance program is critical to demonstrate to employees, your board, and the public that your organization is committed to operating in the highest ethical standards, says Brian Kozik, director of compliance and audit services for the North Shore Medical Center in Salem, MA.

At a minimum, include the following in your monitoring process:

  • Areas of interest to regulatory and enforcement agencies, such as the OIG work plan, the Centers for Medicare & Medicaid Services' policy bulletins, and the Joint Commission on Accreditation of Healthcare Organizations' hot compliance areas.

  • Billing and coding of services.

  • Financial transactions that form the basis for Medicare cost reports, balance sheets, and income statements.

  • Compliance hotline. "I monitor the effectiveness of our Help Line by the credibility we have established, not by the number of calls we receive. Employees feel comfortable enough with the program to call, identify themselves, and ask for assistance," says Kozik.

  • An assessment of your training program's quality to measure whether employees learned all your organization taught them.

    Also, include these facility-specific guidelines in your audits:

  • Acute-care hospitals-Medicare billing for teaching physicians; 72-hour rule; research or grant account billing; prospective payment system (PPS) transfer guidelines; cost reporting, the Emergency Medical Treatment and Active Labor Act; and the Health Insurance Portability and Accountability Act of 1996

  • Physician practices-Evaluation and management coding; relationships with pharmaceutical companies; Medicare billing for teaching physicians; HIPAA; advanced beneficiary notices; and anti-trust/anti-kickback arrangements

  • Rehabilitation clinics-Patient assessment; developing plans of care; and documenting therapy services and progress notes

  • Mental health clinics-Patient assessment/treatment plans and outpatient mental health billing, strong privacy policies and procedures

  • Home health-Medical necessity and PPS-monitoring

  • Insurance Carriers - Advertising; administrative costs; utilization review

    Editor's note: If you have a tip that you would like to share with your compliance peers, please send it to Compliance Monitor Editor Kelly Bilodeau and we'll publish it in a future issue of Compliance Monitor.



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