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On January 17, 2017, a group of compliance professionals and staff from the Department of Health and Human Services, Office of Inspector General (OIG) met to discuss ways to measure the effectiveness of compliance programs. individual compliance program metrics.

Following this meeting, The OIG published guidelines on how healthcare organizations can measure the effectiveness of their healthcare fraud compliance programs.

The resource guide explains how healthcare organizations of all sizes can measure different components of their compliance program. The guide covers how organizations can evaluate standards and policies, administration, stakeholder screening and assessments, training, internal reporting system monitoring, non-compliance discipline, and investigations and remedial measures.

“The purpose of this list is to give healthcare organizations as many ideas as possible, be broad enough to help any type of organization, and let the organization choose which ones best suit its needs,” the federal watchdog wrote. “This is not a ‘checklist’ to be applied wholesale to assess a compliance program.”

Rather than use all the healthcare fraud compliance guidelines, OIG recommends that organizations select a small sample of guidelines to implement in a year. Leaders should choose measures based on the organization’s risk areas, size, resources, and industry segment.

“Any attempt to use this as a standard or a certification is discouraged by those who worked on this project; one size truly does not fit all,” the resource guide stated.

The 54 page resource guide started by identifying improvement strategies for healthcare organizations to use to align their compliance program with healthcare fraud prevention laws. Healthcare organizations should develop and maintain the following standards for an effective compliance program:

  • Appropriate coding policies and procedures
  • Adequate overpayment policies and procedures
  • Updated compliance plan
  • Non-retribution and/or non-retaliation policies
  • Internal and external compliance audit standards and procedures
  • Record retention policy
  • Healthcare stakeholder interaction policies, such as how hospitals and physicians, pharmaceutical and medical device representatives, and vendors should engage with each other
  • Gift and gratuity acceptance policy
  • Standards accountability standards, including how the organization handles incentives, sanctions, and disciplinary policies for employees at all levels
  • Compliance Department operations manual
  • Code of conduct

Each one of these topics is covered in greater detail in the guideline. Having a compliance program in place may prevent healthcare fraud and abuse cases, but healthcare organizations should ensure their program is effective by regularly auditing the program and any internal reporting systems.

OIG suggested that organizations aim to audit their compliance program on an annual basis and use each year’s results to analyze and benchmark their performance. The audit process should ensure that the program and any related systems check for healthcare fraud violations based on updated laws and regulations.

Healthcare organizations may also want to consider using a third party to complete a compliance program audit.

Additionally, the federal watchdog recommended that healthcare organizations develop an internal reporting system for employees to identify potential violations. The system should ensure anonymity and confidentiality for reporting and be easily accessible to all employees in the organization.