7 Elements for an Effective Healthcare Compliance Program

A compliance program is important in this day-and-age, thanks to increasing amounts of healthcare fraud as well as payment reform.

According to the National Health Care Anti-Fraud Association (NHCAA), healthcare fraud financial losses are in the tens of billions of dollars each year. In 2013, The US HHS and The Department of Justice recovered more than $4.3 billion in healthcare fraud and abuse. As medical fraud rates continue to soar, healthcare providers should expect to see an increase in governmental inquires, audits, and investigations.

For medical practices, an effective compliance program can be the first line of defense. The purpose of a compliance program is to promote the prevention of criminal conduct, enforce government rules and regulations, while providing quality care to patients. Compliance programs can help protect practices against improper payments, fraud and abuse, and other potential liability areas. Under the ACA, physicians and group practices are required to establish compliance programs as a condition of enrollment in the Medicare program. Additionally, many commercial insurance plans are also requiring providers to have a compliance plan as a condition of participation.

With fraud enforcement initiatives increasing, medical practices that have not implemented compliance plans risk exclusion from commercial insurance plans and government healthcare programs. According to CMS, the implementation of a good compliance program will aid in better protecting a practice from the risk of improper conduct.

The ACA has seven core elements for an effective compliance program:

1. Establishment and adoption of written policies and procedures to promote the organization’s commitment to compliance.

2. Identification and appointment within the organization of an individual to serve as compliance officer, who will be responsible for monitoring compliance efforts and enforcing practice standards.

3. Establishment of reporting systems to encourage individuals to make complaints regarding compliance items without fear of retaliation.

4. Commitment to conducting formal education and training programs for all levels of employees.

5. Ongoing auditing and monitoring of systems to assess the effectiveness of the compliance program and identify issues.

6. Development of policies to enforce standards of conduct with disciplinary measures for employees who fail to comply with requirements.

7. When vulnerabilities are identified, corrective action must be conducted in response to potential violations.

By implementing a comprehensive compliance program, a practice can find and correct potential vulnerabilities while minimizing billing mistakes, reducing the chance of an audit, increasing payment of claims, reducing the chance of fraud and abuse, and promoting safe and quality care.  Healthcare providers that have not yet implemented a compliance plan should utilize the seven core elements as a foundation for their program.

Laurie Zabel, CHC, CPC is Director of Coding &www.medsafe.com). She is a healthcare professional who has over 25 years of Practice Management and Compliance experience. Laurie is a Certified Professional Coder (CPC), a physician chart auditor, a certified ICD-10-CM/PCS Trainer and is certified in Healthcare Compliance (CHC).


Prior to joining MedSafe, Laurie worked for a large University-Academic Medical Center in New Jersey where she was the Practice Manager for the Department of Obstetrics, Gynecology and Reproductive Sciences. Her experience there included operations management, EMR implementation, policy & procedure development, accounts receivable management, and ensuring staff compliance with OSHA, HIPAA, and EOHSS.