The Scope of an Appropriate Program

A compliance program is a system for communication, investigation, action and monitoring. It is not about simply learning the rules and following them, though that certainly is an integral part of an effective compliance program. Rather, your compliance system shapes how you identify the rules, from your internal directives to applicable governmental and payer rules, and how you relay them. While the basis of a compliance structure is formed with initial establishment and launch, ongoing work is required to ensure the program is running effectively. Almost 20 years ago, I was scheduled to present a compliance workshop in Philadelphia in December 1995. Back then, health care providers and suppliers were much less aware of the need for and value of regulatory compliance programs. The scheduled date was just weeks after the government announced its $30 million settlement with the Hospital of the University of Pennsylvania in connection with alleged reimbursement abuses by its teaching physicians. This settlement formed the cornerstone for Physicians At Teaching Hospitals (PATH), a national compliance enforcement initiative which, during the next several years, netted the government somewhere in the neighborhood of $100 million in settlement monies. In any event, direct mail flyers about my workshop inundated the Philadelphia health care marketplace about three weeks before the speech. I arrived at the hotel conference room on the day of the workshop, looking forward to helping my crowd work through compliance issues. Six people showed up. I would like to say that things are much better today. Certainly there is more awareness, but misinformation abounds and there are still far too many who don’t know what compliance means for their business. You can put in the work to create and run an effective compliance program now or you can do it later. But here’s the thing—later may cost a lot more, especially if responding to government suspicion or whistleblower action. One solution for many home care companies is to establish a thorough, effective compliance program within a more limited scope. When initially establishing a compliance program, a smaller company may forego policies involving fraud, reimbursement or contracting, concluding that these activities are rare and easy to observe, rendering formal procedures unnecessary. Home care companies sometimes create compliance programs that initially focus only on reimbursement rules and do not specifically address issues under the anti-kickback statutes, Stark law issues, contractual arrangements and the like. Conversely, other organizations start with compliance programs that primarily address only the specific relationships the organization enjoys with other providers or payers. Still, others focus initially only on Medicare requirements. These limitations are good short-term solutions, as these bundles of rules are all of vital importance and their proscriptions must be diligently followed, but they can also be effective foundations for expansion. With a limited approach, however, it is important that you require immediate reporting from personnel if they observe something worth a rule or action, even if the subject matter has not yet been integrated into your compliance program. If you don’t yet have written policies to address those issues, the activity should be put on hold as soon as a concern is reported, and your health care counsel should then be contacted for analysis and advice. There is nothing wrong with shaping your compliance program around concerns that affect your immediate operating needs and expanding from there. The key is to remember to expand. Every compliance program must actually resolve identified problems, because failure to resolve a known problem is often more heavily penalized than failure to resolve a problem perpetuated by negligent ignorance.