Medicare- and Medicaid-approved long-term care facilities (LTCs) are under a legal obligation to provide compliance training to all frontline staff, administrative personnel, service providers, and subcontractors—and the third principle which must be established is that of the requirement of having an effective noncompliance reporting program.
Noncompliance is defined as any conduct that does not conform to the law. This is often thought of in relation to quality of care. However, an examination of federal healthcare program requirements reveals that it applies to all service providers and subcontractors as well, and includes the following high-risk areas:
- Agent/broker misrepresentation
- Conflicts of interest
- Claims processing
- Credentialing and provider networks
- Health Insurance Portability and Accountability Act (HIPAA) regulations and data control
- Marketing and enrollment
- Employee and contractor screening
- Pharmacy, formulary, and benefit administration, among others
A failure to ensure that all personnel and first-tier, downstream, and related entities (FDRs) are following Centers for Medicare & Medicaid Services (CMS) guidance can lead to serious consequences, including contract termination, criminal penalties, exclusion, and civil monetary penalties.
The reporting system—which should allow staff to anonymously report noncompliance—must also be fully available to all subcontractors and service suppliers. They should be fully informed via suitable training of the reporting procedure’s existence, and on how to use it. All training must also emphasize the anonymity of the reporting service, either through hotlines, written reports, or other agreed means—and the principle of nonretaliation must be stressed throughout.
In summary, the requirements for education and training in ethics, compliance, and noncompliance reporting are not just for frontline staff or administrators, but for the entire organization, and all service providers involved at any stage in supporting the company.
