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Compliance Program Effectiveness Reviews Post Affordable Care Act
A guest column from Al Bassett, senior vice president, and Dick Kusserow, CEO, of PHTS business ally Strategic Management:

The Office of Inspector General (OIG) recommends that healthcare organizations conduct annual evaluations of their Compliance Programs (CP) to ensure effectiveness. However, the regulatory landscape has changed dramatically since the passage of the Affordable Care Act which mandates CPs as a condition of enrollment and/or participation in Medicare and Medicaid. It is anticipated that CMS will require executive leadership certifications of CP effectiveness along the lines of what is already in place in the State of New York. Add to this the application of the OIG’s Responsible Corporate Officer doctrine. With this in mind, hospital board members and CEOs are asking how CP effectiveness reviews can be more sharply focused to meet the needs of all stakeholders.

Former Inspector General (1981-1992) Dick Kusserow notes that his firm, Strategic Management, takes a different approach from most others in conducting this type of review by making reviews outcome-based evaluations rather than output focused. As such, he believes it is critical to focus on metrics evidencing effectiveness. For example, in the case of compliance education and training, statistics related to numbers of covered persons trained is only part of the picture. The more important aspect is producing evidence of what participants learned from the lessons and whether they are applying them in their daily work routine. This same principle can be applied to all seven elements of the program. In conducting compliance program evaluations, Kusserow believes such reviews should place special emphasis upon examining the following three general areas:

  1. The CP structure and operation beginning at the board level and cascading down through the executive and management leadership and compliance office to all employees, medical staff, contractors, and other affected parties.

  2. Metrics available to evidence effectiveness of CP elements and processes; and where such data is absent, offering suggestions as to how metrics may be added and evidenced.

  3. The effectiveness of ongoing monitoring and auditing of high-risk areas identified by the OIG including ongoing monitoring by program managers that verifies applicable rules and regulations are being addressed by internal controls and written guidance; and that the ongoing auditing by the compliance office and/or internal/external auditors are able to confirm the monitoring and validate that the controls have been effective in reducing errors or violations.
For more information on the services available through PHTS/Strategic Management, please contact Adam B. Allen, MBA, CIW, A+, MCP, INS, ARM, AIS, executive vice president & chief operating officer at PHTS, at aallen@phts.com.