The Basics - What is a Compliance Program and Why Do You Need One?
So, what is a corporate compliance program? Simply stated, it is a written and operational commitment to organization-wide compliance with all applicable laws. This includes laws governing quality of care, like federal OBRA laws and regulations and state licensure laws, fraud and abuse-specific laws like the federal False Claims Act and Anti-Kickback Statute and a variety of other laws governing the delivery of care and claims for payment in NFs.
We wanted to bring this technical concept down to the real world, so we asked some of your professional colleagues “What is a compliance program?” Here’s what they said:
- Compliance programs help us focus on improving quality with limited resources.
- Compliance measures are an investment that advances the goals of the NF, the quality of care provided to residents and the solvency of the federal healthcare programs.
- This is a way for providers to “police” themselves.
- We use our compliance program as an internal control to monitor adherence to applicable statues, regulations, guidelines and, in turn, avoid federal and state allegations of fraud and abuse.
- It’s the formulation of effective internal controls to ensure compliance with statutes, regulations and rules.
So, why do you need a compliance program? Well, why do you need a house? After all, you could live in a tree, or under a tent, instead of a house. It would be cheaper and a lot simpler. You wouldn’t have a mortgage or rent, no yard work, no utility bills. But, then, your quality of life would be driven by factors you can’t control, like the weather. Your house allows you to control the environment in which you live, at least to some degree. You can keep out the weather, monitor the kids, and decide who comes in and who stays out. Having a house, and that control, costs money and takes commitment and time. But, most of us think it’s worth it and, frankly, most of us don’t live in trees or tents.
Compliance programs are the same. They help you control the environment in which your residents live and in which you work. They help you keep out inclement elements that reduce quality of care, create legal risks and liability, dishearten employees and, in the end, cost you money. Like a nice, secure house, compliance programs take investments of time, energy, and money, and sometimes require reallocation of resources. But, there are returns on those investments.
But, don’t take our word for it. Both your professional colleagues and the OIG have given us some thoughts about the benefits of compliance programs. Here’s what they said:
- Our compliance program is a concrete demonstration to employees and the community at large of the NF’s commitment to responsible corporate conduct;
- It helps us obtain an accurate assessment of employee and contractor behavior;
- It helps us increase the likelihood of identifying and preventing unlawful and unethical behavior;
- It allows us to quickly react to employees’ operational compliance concerns and effectively target resources to address those concerns;
- It helps improve the quality, efficiency and consistency of our services;
- It encourages employees to report potential problems and allow for appropriate internal inquiry and corrective action;
- The program creates a centralized source for distributing information on healthcare statutes, regulations and other program directives;
- It’s a mechanism to improve internal communications;
- It includes procedures that allow prompt and thorough investigation of alleged misconduct;
- Our program demonstrates our commitment to honest and responsible corporate conduct;
- It increases the likelihood of preventing unlawful and unethical behavior, or identifying and correcting such behavior at an early stage;
- Our program helps minimize financial losses to the government and taxpayers, as well as corresponding financial loss to the NF through early detection and correction;
- It helps us enhance resident satisfaction and safety through the delivery of improved quality of care;
- It improves our reputation for integrity and quality, increasing our market competitiveness and reputation in the community;
- Our compliance program reflects a sincere effort by our company to comply with applicable statues and regulations through the establishment of a compliance program, and significantly reduces the risk of unlawful or improper conduct; and
- Lots of facility staff say that state surveyors don’t cite us on compliance programs, so why bother? But, surveyors are starting to notice. So are insurance companies who often ask to see our compliance program at annual policy renewal time, and it can affect premiums.
Corporate compliance programs are technically voluntary. No statute or regulation currently requires that a health care provider implement a compliance program. However, compliance with applicable laws is mandatory, whether or not you have a compliance program in place. Compliance programs are designed to help you better understand your operations and to monitor, on an ongoing basis, compliance with applicable laws and your own policies and procedures.
Compliance programs are rooted in the U.S Federal Sentencing Guidelines used by enforcement agencies and courts to determine applicable sanctions for violations of federal criminal laws, including criminal health care statutes and regulations.In addition to prescribing standard sentences, the sentencing guidelines also identify factors that can reduce a prescribed criminal sanction, including having an effective compliance program. So, a provider with an effective compliance program may qualify for reduced sanctions where its employees have violated federal criminal laws governing health care. Finally, even though compliance programs are voluntary, the OIG has made it clear that federal policy and regulatory agencies expect health care providers to design, implement, and maintain effective compliance programs.