Healthcare Compliance: 7 elements for an effective program


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

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.

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.