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1. The Important Components of a
Corporate Compliance Program
By: Laurie Aloi, CPC, CHC
MedSafe
“The Total Compliance Solution”

2. 7 Elements of a Compliance
Program
1.
2.
3.
4.
5.
6.
7.
Standards of Conduct/Policies and Procedures
Compliance Officer/Compliance Committee
Education
Monitoring and Auditing
Reporting and Investigating
Enforcement and Discipline
Response and Prevention

3. #1 Standards of Conduct/Policies
and Procedures
 Code of Conduct:
 Promote your commitment to compliance
 Demonstrate your organizations attitude and
emphasis on compliance and its applicable laws
and regulations
 Build your program around these elements
 Code of Conduct is meant for all employees,
representatives of the organization, vendors,
suppliers, independent contractors, board
members and volunteers

4. #1 Standards of Conduct/Policies
and Procedures
 Policies and Procedures:
 Begin with areas of risk identified within the OIG
workplan:
 Internal assessments
 Self Disclosure
 Regular Medicare sanction checks
 Billing Policies
 Unbundling
 Credit Balances
 No charge visits
 Incomplete/un-successful surgical procedures

5. #2 Compliance Officer/Compliance
Committee
 “Serves as the focal point for Compliance
activities”
 “Appropriate authority is critical to the
success of the program”
 Most Compliance Officers/Committees report
to the CEO or the Board

6. #2 Compliance Officer/Compliance
Committee
 The Compliance Officer/Committee will:
 Oversee and monitor the compliance program
 Report to the governing body, CEO
 Revise the compliance program periodically
 Develop the education and training program
 Assist with internal compliance review and
monitoring
 Independently investigate and act on matters
related to compliance

7. #3 Education
 The most important line of defense for a
Compliance Program!
 The OIG recommends that all employees be
required to have a specific number of hours
of training annually.

8. #3 Education
 Ten elements to include in a basic
compliance training program:
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Body of legal and regulatory knowledge guiding
compliance activity
Organizations compliance philosophy
How to handle compliance communication inside and
outside your organization
How to define and report compliance violations
Policies regarding patient confidentiality and the handling
of patient information
Claims submission

9. #3 Education
 Ten elements continued:
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


Only qualified personnel may perform diagnosis and
procedure coding
Physician documentation is the primary determination for
claims submission
Vendors are held to the same compliance standards as staff
Employees involved in compliance violations will be
disciplined

10. #3 Education
 Corporate Officers, Managers and other staff should receive
Ethics training that includes the following:

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


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Government and private payer reimbursement principals
General prohibitions on paying or receiving remuneration to induce
referrals
Proper confirmation of diagnosis
Submitting claims for physician services when rendered by a nonphysician
Signing a form for a physician without the physicians authorization
Alterations to medical records
Prescribing medications and procedures without proper
authorization
Proper documentation of services rendered
Duty to report misconduct

11. #4 Monitoring and Auditing
 Ongoing evaluation is critical to a successful
compliance program
 Functions common to all organizations that should be
reviewed;
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Anti-kickback and self referral issues
Credit balances
Bad debts
Claim development and submission
Record retention
Cost reporting
Marketing
Compliance program process

12. #5 Reporting and Investigating
 The OIG stresses the importance of
communication:
“An open line of communication between the
Compliance Officer and personnel is equally
important to the successful implementation of a
compliance program and the reduction of any
potential fraud, abuse and waste.”

13. #5 Reporting and Investigating
 Policy for no retaliation or retribution. If not, this may
create whistleblowers
 Confidentiality and anonymity in the reporting
process
 All complaints and investigations are monitored and
tracked

14. #6 Enforcement and Discipline
 Compliance program should include a written
policy setting forth the degrees of disciplinary
actions that may be imposed for failure to
comply with standards
 The policy should include the following 5 points
1.
2.
3.
4.
5.
Non-compliance will result in discipline
Failure to report non-compliance will result in discipline
An outline of disciplinary procedures
A list of the parties responsible for appropriate action
A promise that discipline will be fair and consistent

15. #7 Response and Prevention
 Violations of compliance programs threaten
an organizations status
 Failure to respond, or to engage in lengthy
delay can have serious consequences
 If a problem is found the first step is to meet
with your legal counsel to determine the
severity and develop a plan of action
 OIG requires prompt reporting to the
appropriate authority within a reasonable
time, but not more that 60 days

16. #7 Response and Prevention
 Thorough documentation of the investigation
must be available
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Description of the potential misconduct and how it was
reported
Description of investigative process
List of relevant documents reviewed
List of employees interviewed
Employees interview questions and notes
Changes to Policies and Procedures, if appropriate
Documentation of disciplinary actions, if any
Investigations final report with recommended actions
 Voluntary Disclosure