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Compliance Hotline

Policy Statement

[PROVIDER] will maintain a toll free Hotline [PROVIDER’S TOLL FREE NUMBER] to enable an individual to report any suspected violations of the law, Federal healthcare regulations, policies or procedures or the [PROVIDER’S] Standards of Conduct. The Hotline will be available from 8:00 AM – 5:00 PM. Voice Mail will be available after hours. All voice mail calls will be returned the next business day. A letter may be submitted via mail [PROVIDER’S ADDRESS] or fax [PROVIDER’S FAX] in lieu of calling the Hotline number. [PROVIDER] will publicize the existence of the Compliance Hotline and display information regarding the Hotline in an employee area.

Suggested Elements

To achieve the goal of regulatory compliance, providers may wish to include the following suggested elements in their corporate compliance policy:

  1. Operation:  The Compliance Officer must maintain the operation and integrity of the Compliance Hotline.  Primary responsibilities include:
    • Ensure the proper functioning of the Hotline;
    • Conduct appropriate investigations of all credible allegations; and
    • Follow-up appropriately in response to all Hotline calls to:
      • Provide feedback to callers as necessary;
      • Report Compliance Hotline activity to [PROVIDER’S] governing board on a consistent/regular basis; and
      • Maintain a secure area for all documentation.
  2. Confidentiality: The Compliance Officer will keep all reported information confidential by:
    • Refraining from requiring the caller to disclose his/her identity;
    • Assuring anonymity;
    • If/when an employee chooses to disclose his/her identity; holding it in confidence to the fullest extent practical or permitted by law;
    • Refraining from recording the Compliance Hotline call and refrain from identifying the number/location of the call;
    • Keeping the Compliance Hotline Report as the only record of Compliance Hotline calls; and
    • Maintaining the Compliance Hotline Report in a secure area.
  3. Retaliation: No retaliatory actions will be taken against any individual who reports compliance violations in good faith through the Compliance Hotline.
  4. Communication: The [PROVIDER] will communicate to all employees the existence of the Compliance Hotline by:
    • Developing a Hotline Poster that states the Hotline number and hours of operation;
    • Displaying the Poster in a prominent location within the facility frequented by employees;
    • Providing Compliance Hotline information/instructions to all employees during orientation and annual compliance training; and
    • Developing a Compliance Newsletter that advertises the Compliance Hotline.
  5. Tracking: The Compliance Officer will track all Compliance Hotline calls by:
    • Tracking all calls by using Hotline Report Forms sequentially numbered according to date;
    • Providing the control number to the caller as a tracking number so that the caller may call back anonymously and inquire about the status of his/her prior call; and
    • Creating case files for each complaint and keep in a secure area.
  6. Operation: The Compliance Officer must establish the times of operation and the process for “after hour” calls.  All calls should be returned by the next business day at the latest.
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