Compliance Laws and Regulations on Different Healthcare Organizations

Healthcare Compliance Programs
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Table of Contents
Part A: Physician Offices…………………………………………………………………..3
Part B: Nursing Homes…………………………………………………………………….5
Part C: Hospice……………………………………………………………………………..7
Part D: Ambulance Services……………………………………………………………….9
Part E: Third-Party Billers……………………………………………………………….11
Part F: Durable, Medical, Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Providers……………………………………………………………………………………13
References…………………………………………………………………………………..15
Healthcare Compliance Programs
Part A: Physician Offices
A compliance program fosters healthcare providers’ adherence to regulations and statutes implemented by the federal government, such as Medicaid and Medicare. The Office of Inspector General (OIG) gives proper guidance on how physician offices can create voluntary compliance programs to eliminate or decrease instances of improper billings and prevent fraudulent activities. In addition, the Affordable Care Act (ACA) mandates health providers to create and implement an effective compliance program by following these seven steps. First, developing standards of conduct to identify distinctive types of fraud-and-abuse problems that might arise in the field of practice. The guidance from the OIG identifies some risk areas, such as billing and coding, home care services certification, healthcare coverage uncertainties, using Medicare symbols illegally, documentation, and improper inducements (Kennedy, 2001). Second, establishing an oversight method. There must be a good mechanism in place to ensure that established rules are followed. In the case of physician offices, it might not make sense to appoint a compliance officer. The OIG’s guidance requires health providers to have compliance contacts, who might be an office manager, primary biller, or a third-party billing company. Some of the duties of a compliance contact include monitoring the implementation of the compliance program, revising and updating it accordingly, improving the quality of services via auditing, and coordinating the compliance training program. Third, conducting staff training. All employees should know how the compliance program affects their work, how to comply with it, and the consequences of violating it.
Fourth, creating communication channels. Employees at the physician's offices should be able to report fraudulent activities without fear. Effective communication channels, such as hotlines and anonymous drop boxes, should be available. In some instances, an open-door policy between the compliance personnel and physicians might be adequate. Confidentiality should always be safeguarded to encourage reporting of fraudulent activities, and employees ought to understand that, at some point, they might be required to disclose the information to law enforcement agencies (Kennedy, 2001). Fifth, performing monitoring and auditing functions. The standards for which employees are held accountable by the compliance program should be evaluated regularly to promote timeliness, completeness, and accuracy. Sixth, enforcing standards and applying discipline. The compliance program should be consistent and appropriate, in a way that employees who fail to report violations should be subjected to disciplinary actions. Seventh, responding to detected offenses appropriately. All errors and overpayments should be reported to the OIG using the right protocol regardless of whether they occurred intentionally or unintentionally.
One example of a compliance program within the physician's office is the physician and dental practices. Indeed, it facilitates the implementation of a compliance program that is aimed at waste, abuse, and fraud prevention (Stdtac.org, 2016). At the same time, the compliance programs advance the objective of quality patient care prevention. Another example of the medical necessity for laboratory diagnostic procedures. In particular, diagnostic procedures are medical necessities, and physicians cannot function effectively without them. However, a voluntary compliance program is appropriate to ensure that laboratory procedures are performed appropriately and that any error or fraud is reported using the right channel.
Part B: Nursing Homes
The Patient Protection and Affordable Care Act (ACA) relates to nursing homes in various ways. In particular, it requires nursing facilities to have highly skilled personnel to ensure that the quality of patient care is not compromised (McGuire, 2020). For Medicare or Medicaid patients, proper billing of the healthcare services offered must be done using the right procedure. In addition, nursing facilities are entitled to implement an effective compliance program. The OIG’s guidance must be adhered to when creating such a program. Nursing homes are prohibited from patient abuse. Patients’ information should be kept confidential. The ACA provides a framework that puts nurses at the center when it comes to providing quality patient care and proper financing of healthcare services (Cleveland, Motter, & Smith, 2019). Nursing homes are subject to promote patient care accessibility, quality, and affordability. Consequently, the ACA requires nursing homes to report errors, uncertainties, and fraudulent activities to the Secretary of Health and Human Services (HHS) who has the mandate to waive penalties if these facilities are transparent and implement proper systems to identify and prevent them in the future.
A nursing home compliance program is beneficial and nursing facilities should implement it. First, it enhances operational effectiveness, reduces overall costs, and improves the quality of patient care. Second, it promotes consistency, efficiency, and accessibility of quality healthcare services. Third, it ensures compliance with federal and state regulations and statutes. Fourth, a nursing home compliance program enables facilities to identify and prevent unlawful and unethical behavior among health providers. Fifth, it encourages employees to report fraudulent activities and other problems for proper investigations, which can lead to the reduction of penalties or fines by up to 90% (Fukushima, 2017). Overall, it improves organizational management and communication.
The two examples of compliance programs within nursing homes are the River Bluff Nursing Home Compliance Program (RBNHCP) and Friends Homes Compliance and Ethics Program (FHCEP). Both these compliance programs have implemented procedures and policies to prevent abuse of business operations, fraudulent activities, and to ensure high standards of patient care. The RBNHCP and FHCEP are licensed highly skilled nursing facilities. The most significant things about effective compliance programs are that they foster adherence to established regulations, workplace behavior, eliminate or decrease penalties, and make employees to be committed to their duties entirely (Friends Homes, 2018). Residents receiving healthcare services are respected and their rights are not violated. As a result, compliance programs in nursing homes are crucial since they create a conducive environment for patients and healthcare providers.
Part C: Hospice
The OIG identifies various major risk areas that are specific to hospice compliance. First, admitting patients who are not terminally sick to hospice care (Reinhart Hospice and Palliative Care Practice Group, 2016). Before a patient is admitted to hospice care, the person must have been diagnosed with an incurable or terminal disease. In that light, hospice facilities that might admit patients without terminal illnesses to make profits should be subjected to the law. Besides, it is clear that the beneficiary of hospice should have a prognosis of a terminal disease and the expected life expectancy is six months. Second, falsified care plans or medical records. Specifically, this is a significant risk area and hospice care should not indulge in such practices. All medical records should be accurate and no forging should be done so that a patient can meet the minimum requirements for admission to hospice care.
Third, another primary risk is the insufficient patient oversight, particularly the one receiving over 6 consecutive months of care in a hospice facility. The hospice is given the responsibility of evaluating the terminality of its patients continuously. The moment it realizes that a specific beneficiary no longer fulfills the minimum requirements, the facility must initiate a discharge. Fourth, hospice incentives to potential or actual referrals, such as patients and nursing homes, might violate the federal and state regulations or statutes, or the Anti-Kickback Statute, including poor arrangements with nursing facilities (Reinhart Hospice and Palliative Care Practice Group, 2016). The hospice is always expected to adhere to all established regulations when providing quality services to terminally ill patients. Fifth, knowingly billing patients for substandard or inadequate care. In particular, hospice should always bill patients for high-quality healthcare services that have been provided by licensed and qualified physicians. Altering patients’ medical bills is unacceptable, unethical, immoral, and illegal.
Excellent examples of evidence of compliance programs within hospices include Avow Hospice Corporate Compliance and Ethics Plan (AHCCEP) and St. Croix Hospice Compliance Programs. These compliance programs for hospice enhance the provision of quality patient care and foster the integrity of facilities. As discussed in the paragraph above, there exist numerous risk areas in hospice care and the best method to avert them is by implementing an effective compliance program. On that note, St. Croix Hospice and Avow Hospice are committed to establishing and promoting a culture of fraud detection and pr...