‘Why Bother?’

Compliance programs make much sense. They provide a logical, structured format to identify and implement the company’s best practices, and to fix problems as they arise.

Sure, they cost time and money to create, implement and operate effectively. But the dividends are many and varied. An effective compliance program accomplishes five tasks.

  1. Captures policies and standards of conduct which a company finds important.
  2. Communicates these policies and standards to company personnel. It also ensures that the personnel know how the policies apply to them, as well as what to do when they believe policies are not being followed.
  3. Provides a mechanism to investigate any flagged problems or concerns.
  4. Provides methods for fixing problems and for enforcing program violations.
  5. Includes provisions to audit whether a company is following its policies, and also to monitor whether a company is doing a good job of disseminating information and reporting, investigating and fixing problems.

But, many healthcare providers seem to disagree with me about the importance of compliance programs. I have presented talks and workshops about compliance well over 100 times. I have written or been quoted in hundreds of articles about compliance and compliance programs, over 20 years, and there are thousands more articles in cyberspace.

Despite this overabundance of information about compliance programs, many healthcare organizations—maybe yours, too—have not created an operational, effective compliance program.

Many, many homecare companies, as well as every other variety of healthcare providers, continue to operate with no compliance program in place, or with half-hearted attempts that fail the “effectiveness” test.

Why?  Well, I propose the reason is because of the “Why bother?” questions they ask themselves, but dare not verbalize:

Q: Why bother? After all, effective compliance programs cost too much to establish and operate.
A: Like insurance, they are necessary expenditures. Besides, how much money are you losing to payer audits, claims reviews, records deficiencies and the like?

Q: Why bother? After all, a compliance program will identify problems that will cost me money to correct.
A: Maybe so, but the benefits—financial and otherwise—are well worth the cost.

Q: Why bother? If I don’t know what I am doing wrong, I won’t get into trouble.  But if I know it’s wrong, the compliance program will get me in trouble.
A:  Ignorance is not a defense. Ask anyone who has been audited.

Q: Why bother? They won’t go after companies that only have a small quantity of Medicare billings.
A: They routinely go after this type of company—every day.

These questions are rarely voiced explicitly, but listen closely. They manifest themselves when your billing manager suggests that imprecise billing is not a concern, because the payer will check and won’t reimburse you if it’s wrong. They manifest themselves when senior management wants to woo referral sources with reduced paperwork promises or with space rentals, service contracts or other financial incentives. They manifest themselves when compliance recommendations are rejected because “we won’t get caught anyway” or because of potential negative impact on revenues, or because the problem was caused by a physician who refers a lot of business to your company. And so forth.

The short answer to all these “Why bother?” questions is: “Because you are crazy not to bother.”  The longer answer is that an effective compliance program offers many benefits. It can prevent trouble, in a variety of ways.  But it can improve bottom line reimbursement, and can enhance relationships with personnel and with outside partners as well.

In fact, I have identified at least 21 benefits of an effective compliance program. These benefits fall into three general categories. Seven benefits involve helping you follow the rules, be they federal laws, payer communications, or simply your company’s own internal policy decisions. Another six benefits are ways that an effective compliance program helps improve your company’s internal communication and personnel relations. This category can help a homecare company create a very powerful organization.  Finally, eight benefits focus on ways an effective compliance program may help your company pursue growth opportunities. 

Why bother, indeed!