Compliance Program Standards

It is essential that health centers maintain effective compliance programs.  

As part of the Patient Protection and Affordable Care Act (Affordable Care Act), compliance programs will become mandatory conditions of enrollment in Medicare, Medicaid and CHIP.  

All health care providers face heightened scrutiny of their operations in the current environment of increased health care fraud and abuse enforcement and overpayment recoupments, together with providers’ duty to self-disclose violations and promptly return overpayments, as well as the possibility of whistleblowers’ filing False Claims Act claims.

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recommends that compliance programs include the following seven elements:

  1. Written policies and procedures that describe compliance expectations and program; 
  2. Designation of an employee vested with responsibility for the day-to-day operation of the compliance program;
  3. Conducting internal compliance monitoring and auditing; 
  4. Training and education of all affected employees and persons, including executives and Board members, on compliance issues, expectations and the compliance program operation;
  5. Communication lines to the responsible compliance position that are accessible to all employees, persons associated with the provider, executives and governing Board members, to allow compliance issues to be reported;
  6. Disciplinary policies to encourage good faith participation in the compliance program by all affected individuals; and, 
  7. A system for responding to compliance issues as they are raised.

For health center compliance programs, the emphasis should be on implementing, evaluating and improving these elements so as to focus on risk areas affecting the health center.