OIG posts hospital compliance guidelines

Home care procedures under development

The Office of Inspector General (OIG) of the Department of Health and Human Services recently posted on its Web site (http://www.dhhs.gov/progorg/oig/) its long-awaited voluntary compliance guidelines for hospitals. The OIG says it will post similar compliance guidelines for home care agencies in the near future, possibly in four months.

The intent of the guidelines, the OIG says, is to help hospitals develop internal controls that ensure "adherence to applicable federal and state law, and the program requirements of federal, state, and private health plans."

The Medicare watchdog agency asserts that such programs will "significantly advance the prevention of fraud, abuse, and waste in these health care plans while at the same time furthering the fundamental mission of all hospitals, which is to provide quality care to patients."

The OIG reminds providers that "while this document presents basic procedural and structural guidance for designing a compliance program, it is not in itself a compliance program." Rather, the OIG expects hospitals to use these guidelines to develop their own compliance programs. (For more on compliance programs, see Hospital Home Health’s compliance issue, February 1998.)

The OIG acknowledges there is no single "best" hospital compliance program but maintains that the basic elements of its guidelines "can be used by all hospitals, regardless of size, location, or corporate structure."

According to the OIG, a minimum, comprehensive compliance program should include the following seven elements:

1. the development and distribution of written standards of conduct, as well as written policies and procedures that promote the hospital’s commitment to compliance (e.g., by including adherence to compliance as an element in evaluating managers and employees) and that address specific areas of potential fraud, such as claims development and submission processes, code gaming, and financial relationships with physicians and other health care professionals;

2. the designation of a chief compliance officer and other appropriate bodies, e.g., a corporate compliance committee, charged with the responsibility of operating and monitoring the compliance program, and who report directly to the CEO and the governing body;

3. the development and implementation of regular, effective education and training programs for all affected employees;

4. the maintenance of a process, such as a hotline, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation;

5. the development of a system to respond to allegations of improper/illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations, or federal health care program requirements;

6. the use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas;

7. the investigation and remediation of identified systemic problems and the development of policies addressing the non-employment or retention of sanctioned individuals.