If you’re hearing more about healthcare compliance, it’s primarily because of increasing government oversight and regulatory actions. Healthcare compliance requires a proactive, comprehensive, and well-organized program to safeguard patient safety and improve care quality—all while ensuring that healthcare business operations are conducted within the parameters of regulations. These responsibilities require the specialized expertise and experience of a healthcare compliance officer (HCO).
The importance of healthcare compliance
Federal healthcare compliance
At the federal level, compliance efforts focus mainly on fiduciary oversight. The U.S. Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) is particularly attuned to healthcare compliance in protecting federal programs from fraud, waste, and abuse.
The OIG has published guidance for healthcare organizations on how to structure their compliance programs. To comply with the OIG, healthcare organizations must address the seven elements of an effective compliance program.
Accreditation compliance
On top of adherence to federal regulations, healthcare compliance officers must also comply with their chosen accreditation body’s standards. These non-governmental, third-party accreditors receive deeming status from The Centers for Medicare & Medicaid Services (CMS) to promote high-quality healthcare through accountability and public disclosure using various quality initiatives. The most prominent accreditors are:
- The Joint Commission (TJC)
- Det Norske Veritas (DNV)
- The National Association for Healthcare Quality (NAHQ)
- The Agency for Healthcare Research and Quality (AHRQ)
Who’s responsible for healthcare compliance?
The governing body of a hospital or health system is ultimately responsible for the conduct of the organization and its overall compliance. While the healthcare organization’s administrators may assign this responsibility to a compliance officer or team of compliance professionals, every employee of the organization has a responsibility for compliance in their day-to-day role.
The OIG specifically recommends the designation of a compliance officer and provides guidance that the individual should be a high-level official with direct access to the governing body and the CEO. Multiple individuals typically work in the compliance department under the direction of the HCO.
Additionally, the OIG recommends healthcare organizations have a compliance committee for advice and assistance in the implementation of the compliance program.
The healthcare compliance officer’s job responsibilities
The Compliance Officer’s responsibilities in provider and payer organizations largely align with the OIG’s seven elements of an effective compliance program and include the following:
- Oversee and monitor the organization’s compliance program
- Report on a regular basis to the organization’s CEO and the compliance committee on the activities of the compliance program
- Revise the compliance program periodically in response to changes in regulations and in accordance with the organization’s needs
- Develop and coordinate an educational training program for employees on the elements of the compliance program and ensure employees are knowledgeable of relevant federal and state regulations
- Ensure that independent contractors who provide services in the organization are aware of applicable compliance requirements
- Work with HR to ensure all employees and contractors have been screened and checked against sanction and exclusion lists
- Assist in internal compliance reviews and monitoring activities
- Investigate and act on compliance matters, including coordinating corrective actions
- Develop policies and programs that encourage employees to report suspected compliance issues
The compliance committee also holds responsibilities in the organization, including the analysis of the organization’s risk, assessment of policies and procedures addressing risk areas, and monitoring internal systems and controls to accomplish the organization’s compliance objectives. Today’s compliance software provides many of the tools compliance committees require to fulfill their obligations in supporting the healthcare compliance officer.
Qualifications & skills of a healthcare compliance officer
A healthcare compliance officer usually holds a bachelor’s degree in a healthcare or related field such as nursing or healthcare administration. Increasingly, they may also have a master’s degree in health administration, business, or law. An HCO would typically have 5-10 years of experience in compliance or a leadership role in healthcare operations or management.
Healthcare compliance officers may also have certifications such as Fellow in the American College of Healthcare Executives (FACHE) or Certified in Healthcare Compliance (CHC). They are members or active in associations such as the Health Care Compliance Association (HCCA) or the Society of Corporate Compliance and Ethics (SCCE).
While healthcare compliance officers must be familiar with the many laws and regulations that govern their healthcare organization, they also must understand the financial aspects of the healthcare business. This includes coding and billing of medical claims and the reimbursement audit process.
The healthcare compliance officer should be a highly ethical person who prioritizes the protection of their organization and is able to act in an unbiased and fair manner. They must act and investigate compliance concerns confidentially. They need to be proactive, organized, and trustworthy—while realizing that they could be put in a position to make difficult, unpopular decisions.
Challenges for healthcare compliance officers
Healthcare compliance officers are involved in a variety of complex regulatory issues and face growing challenges in their position. Staying knowledgeable of the constant changes in compliance requirements is a huge undertaking and perhaps the biggest challenge. Additional challenges facing healthcare compliance officers include:
- Creating and cultivating a culture of compliance within the organization
- Ensuring all employees receive training on compliance and regulatory issues affecting their jobs
- Ensuring all policies and procedures are compliant with current regulations and upholding the organization’s core values
- Educating department directors, administrators, the CEO, and the governing board of the importance of compliance, and speaking up to leaders when compliance is jeopardized
- Investigating compliance concerns with confidentiality and safeguarding employees who discover them
- Advocating for adequate budget and funding for necessary compliance activities
Rewards of the job
Adherence to federal and state laws and regulations will always be mission critical in healthcare. The trend of government oversight of healthcare will only continue as payment models link reimbursement revenue to quality and compliance.
