The Office of Inspector General (OIG) for the US Department of Health and Human Services (HHS) has made educational resources available for healthcare providers to comply with federal healthcare laws and regulations. The compliance documents include special fraud alerts, advisory bulletins, podcasts, videos, brochures, and papers providing guidance on compliance with federal healthcare program standards.
The educational resources include:
- A Roadmap for New Physicians: This is designed to assist in teaching physicians about the federal laws that protect Medicare and Medicaid programs and program beneficiaries from fraud, waste, and abuse.
- Corporate Integrity Agreements: The OIG negotiates corporate integrity agreements (CIA) with healthcare providers and other entities as part of the settlement of federal healthcare program investigations arising under a variety of civil false claims statutes. Providers or entities agree to the obligations, and in exchange, OIG agrees not to seek their exclusion from participation in Medicare, Medicaid, or other Federal healthcare programs.
- Toolkits: The OIG has created several toolkits to help providers ensure they are in compliance with healthcare laws. The toolkits include:
- Measuring Compliance Program Effectiveness: A Resource Guide
- Adverse Events Trigger Tools
- Handout: A Toolkit for Healthcare Boards
- Advisory Opinions: HHS-OIG issues advisory opinions about the application of certain fraud and abuse enforcement authorities to the requesting party’s existing or proposed business arrangements.
- Voluntary Compliance: OIG has several self-disclosure processes to report fraud in HHS programs.
- RAT-STATS: This is a free statistical software package to assist in claims review.
Additional materials available on the website include:
- Supplemental Compliance Program Guidance for Nursing Facilities
- Compliance Program Guidance for Nursing Facilities
- Safe Harbor Regulations
- Special Fraud Alerts, Bulletins, and Other Guidance
The HHS-OIG Compliance Education webpage containing the above listed resources can be accessed at Compliance | Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services (hhs.gov).
Issue:
The OIG and the Centers for Medicare & Medicaid Services (CMS) require skilled nursing facilities to have a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations under the Social Security Act, and in promoting quality of care. Training and education on healthcare compliance is essential for all staff members, especially compliance and ethics committee members. Routine audits should be conducted of monetary transactions, with the results reported to the compliance and ethics committee and the governing body. The audits should have a corrective action plan if a discrepancy is found, and all discrepancies should be investigated and rectified immediately. It is imperative that every facility has a robust and effective compliance and ethics committee to reduce the likelihood of healthcare fraud, waste, and abuse of government funds.
Discussion Points:
- Review your policies and procedures for operating an effective Compliance and Ethics Program. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff on your compliance and ethics policies and procedures upon hire and at least annually. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure that all staff are aware of compliance and ethics policies and guidelines and understand their responsibility to report any concerns to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Ensure that routine audits of accounts receivable and payable are performed, that financial transactions are supported by accurate documentation, and that correction is made to any identified violations. Provide the audit information and any necessary action steps to the compliance and ethics committee and the governing body.
