United States: Maintaining An Effective Corporate Compliance Program

Many health care organizations have developed corporate compliance programs. Once key elements of the compliance plan are established however, the larger challenge becomes monitoring the effectiveness of the program and making necessary modifications to maintain the program's integrity. The following is a list of factors to consider when evaluating the effectiveness of your existing compliance program.

Not only has the Office of Inspector General ("OIG") stated that the existence of a Compliance Program will be factored into decisions regarding penalizing providers, but the effectiveness of the program will also be considered. A report from the OIG on the Government Industry Roundtable noted that documentation is the key to demonstrating the effectiveness of a provider's compliance program.

To demonstrate the effectiveness of your program, do the following:

• Document the medical necessity for services and supplies provided by your organization. Note that the Model Compliance Program issued by the OIG stresses the importance of documenting the medical necessity for tests ordered even if the tests are ordered by physicians who are not employees of the organization.
• Document that the organization has a mechanism in place to enable employees to anonymously report compliance concerns in good faith without retaliation from the organization for reports. Further, document your process for ensuring that identified overpayments are disclosed or repaid to the appropriate program.
• Document the organization's training and education initiatives used to ensure that employees understand the rules that apply to their job functions.

Although compliance policies and procedures may be developed by an organization, they have little impact unless employees get the message that management is committed to doing things the right way and will correct problems if they are found to exist. Management must communicate through words and demonstrate through actions its commitment to an effective compliance program. Once employees understand management takes compliance issues seriously, they are inclined to follow the lead.

One key to creating a culture of compliance is a training and education program with the support of senior management. One option is to launch a compliance training and education program with a video produced internally. The video can feature management team members, including the organization's CEO and corporate compliance officer. High-ranking management team members can stress the importance of compliance and of reporting areas of concern to the organization through its various reporting mechanisms. Videos can prove effective and help employees feel comfortable raising compliance questions after completing the training.

The organization must also allocate adequate resources of both time and money to compliance program development and operation. If employees sense true management support for the compliance program, they are more likely to support the program and establish a culture of compliance.

After training employees and informing them of their responsibilities, ensure that they are really doing what they should be doing. Identify some high-risk areas and then review those areas to make certain you are in compliance. You may know some of your own high-risk areas from past experience. Other high-risk areas can be identified by monitoring industry bulletins and by reviewing the Office of Inspector General Workplan. The year 2000 Workplan of the OIG was released October 5, 1999 and is available at the OIG's website at www.dhhs.gov/progorg/oig/.

Monitoring procedures are built-in quality checks within the organization to verify that existing compliance policies are being followed. These include making certain that the reporting hotline is operational and that calls placed to the hotline are being investigated and answered. In addition, monitoring means that disciplinary actions for failure to comply with compliance policies are administered consistently. Routine monitoring checks should be a part of the organization's day to day business practices.

As a corporate compliance program is developed and the organization gains experience with compliance, changes and updates are inevitable. It is easy to become distracted from the mission of compliance with leadership changes, financial constraints and organizational restructuring. An organization's Compliance Plan and Code of Conduct should be modified to respond to internal and external changes in the health care environment. In addition, content and methods of training, audit techniques, and program procedures may need to be updated to conform to industry changes. In order to maintain its effectiveness, a compliance plan must be modified as necessary to keep pace with health care's changing regulatory and business environment.