When we speak about Health First Medical Group Compliance Program, we should underline that this is a formalized effort to prevent, detect, and respond to business accomplishment that is not in agreement with federal and state laws which is more important with an organization’s values. Such programs are of a great importance in the healthcare industry as it usually receives noteworthy financial sustain from the government. This is maintained through such programs as Medicaid and Medicare. The government works out regulatory requirements and monitors audits failure in order to meet the dogmatic requirements; otherwise a bad audit can become the matter of the organization’s fines, penalties and what is worse, exclusion from government programs. The government in such a way ensures that the federal and state healthcare money are appropriately spent.
What goes beyond usual business expectations is the duty of this healthcare organization is to serve the common good, providing necessary services to the community. The society and the public-at-large often need more business practices that are beyond criticism of healthcare organizations. Honesty, therefore, is crucial for a Health First healthcare organization and a compliance program is worked out to validate the inherent organization’s integrity.
Compliance officers can also be named performance auditors as they make sure businesses and organizations follow the increasing maze of laws, permits, regulations, and licensing requirements as it should be. People of such profession may work for the reviewing organizations, or for some external companies of numerous working environments of different types. Because of such variety, compliance officers necessitate extensive specialized education or training. Most compliance officers have worked for the company for many years, in many facets including coding, internal auditing and physician education. This work needs leadership skills. Compliance officer’s mission is to promote the message of Compliance and accept it as part of the culture to allow change in physicians habits and not appear to be a burden on them, but rather work together as a team. “After all, a physician got into practice to treat the patient not to be worried about whether he/she had enough bullet points on the exam, for example. Many years later, we are part of makeup that is the practice, and we rely upon heavily and heartedly accept the whole. When that is the case you can be sure you are a stronger company for it.” (Interview)
Health First Medical Group Compliance Program is dedicated to maintain a culture of integrity. The idea of a compliance program is not just assigned to one appropriate department or person, but to a certain extent it is the duty and responsibility of each member in the organization. The analyzed Health Compliance Program is a management function designed to maintain awareness and monitoring and promote compliance with the laws. In the effort of compliance officer is assisting and validating active compliance all through the organization. This compliance program unites several distinct goals.
Firstly, the strong point of such program is to ensure ethical and legal conduct through the development of policy and education (Training and Record, Orientation Trainings). This gives an opportunity for each member of the team to perform their functions in the system and to be sure they do everything correctly.
Another feature is serving as an internal control to the compensation and payment areas (Audit Documents, Request Documents, Corrective Documents, etc). This becomes essential, as it is a well-known fact that such claims and billing operations are frequently the source of abuse and fraud in the business. Through early recognition and reporting this program can diminish the loss to the government from false claims and reduces the hospital’s spotlight to civil costs and penalties, wrong sanctions, and administrative remedies.
The program is well- planned as it provides a central coordinating mechanism for putting in order and disseminating information and guidance on related federal and state statutes, requirements and regulations. The Health First Medical Group compliance program is worked out as a developed procedure that allows the prompt, thorough examination of alleged misconduct by the association and initiate immediate and fitting corrective action.
The main line Health’s compliance program operates in a special way. Firstly, the Main Line Health Compliance Program has been worked out with the Office of Inspector General’s Compliance Guidance for Hospitals. As there are several definite elements in such program, we shall analyze and each of them. In the discussed curriculum, each element is designed for prevention, detecting, and responding to company conduct that is not conventional of appropriate laws or regulations.
The first element is /compliance Committees Minutes of Meetings, in other words Standards of Conduct. In other words, this is the work of an inspector and the Auditing & Compliance Department that consists of the development and allocation of written principles of conduct, as well as written policies that promote the hospital’s obligation as to compliance and their maintaining throughout organization
The second very urgent component is the compliance infrastructure. This is also known as the description of a chief compliance officer, reporting directly to the health system CEO, the governing bodies, and those, who manages the program procedure; dynamic participation by a committee of compliance and a management committee that includes higher-ranking leadership charged with the liability of monitoring the program.
The third one is the education and training that is worked out in order to develop and implement of regular, effective education and teaching programs for all employees.
The fourth element is the process to receive complaints. During this period, the company tries to maintain a conformity hotline, the Comply Line in order to receive complaints. Here, the company also must adopt procedures in order to protect the anonymity of complainants and whistleblowers from retaliation.
Another strong side of the program that should be underlined is known as system to respond to allegations, that is developed as a system of allegations of improper/illegitimate activities and the enforcement of proper disciplinary action against workers who have violated inside compliance policies, regulations, applicable statutes or central requirements of healthcare program. One more feature of the program is audits to monitor compliance that is regularly used and assist in the decrease of identified problem areas.
Most specialist find the system to investigate problems very helpful in the work of a corporate compliance officer as it makes the main line of the Health’s compliance program function more effective.
The Main Line Health Compliance Program is modeled as an Office of Inspector General’s Compliance Guidance for Hospitals and consists of specific elements, determined to prevent business conduct that does not need be conventional for applicable laws or regulations. The program considerably reduces the risk of unlawful conduct in the healthcare organization operations.
However, we also have to speak about risk areas that the compliance program manages today. Main Line Health operates in a multifarious environment, needs to distinguish between numerous regulatory bodies, and is open to the elements of various risks. Here, we can enumerate several risk areas that are addressed through the compliance health program:
- Capitulation of exact claims and the Federal False Claims Act.
- HIPAA Privacy and Security Rules.
- The referral statutes: The Physician Self-Referral Law and the Federal Anti-Kickback Statute.
- The Emergency Medical Treatment and Active Labor Act (EMTALA).
- Inducements to Medicare or Medicaid beneficiary.
- Expenditure to reduce or limit services.
- Excellence of care which fails to meet standards of healthcare.
- Billing Medicare or Medicaid in excess of usual charges.
Based on above mentioned, it becomes possible to conclude about advantages and disadvantages of ethical compliance in a healthcare organization.
The program of ethical compliance within the healthcare organization was done for the benefit of the business and the staff. The apply of ethical principles can both trim down the chances of a workplace lawsuit and help out to create an affirmative work environment. It has both advantages and disadvantages.
Firstly, local, state and federal laws are helpful in guiding a greater part of a company’s ethical policies. Ethical compliance helps organizations to develop a work culture that is regulated by the workplace laws and diminishes the fines and lawsuits costs.
Workplace Culture is created in the organization as a respect treatment for each worker. It gives equal access to improvement opportunities for employees, and the workplace turns into a positive and encouraging environment. Besides, a strong ethical set in the workplace results the creation of strong working relations between the management and staff. It diminishes employee turnover, gets better morale and positively effects productivity.
On the other hand, such program lacks management support that is one of the disadvantages of the compliance program. It requires the comprehensive sustain of management in order to be effective. The point is that if managers decide to apply own version of corporate ethics, then this conflict of principles can become the cause of confusion in the workplace.
Another disadvantage of the program is its cost, as it is well-known that in order to develop, implement and maintain an ethics compliance program within organization a company has to spend much money and time. However, this is paid off.
To progress the programs we can suggest maximum use of strategies to enhance compliance. Firstly, it is necessary to use a multilevel approach that requires various educational and behavioral strategies. Another suggestion is to use careful techniques of assessment and helpful strategies of promoting patient, provider, and organizational behaviors. In addition, such a program should take into account social, cultural, and psychological factors that affect behavior at every level and must be understood and respected.
Very important here is to use multilevel approach. That means patients, providers, and healthcare organizations try to integrate their efforts for better managing the problem of noncompliance.
Further research is needed to work out the actions and strategies for improving compliance. Significant areas that require research include identifying possible persons at highest risk for noncompliance, as well as methods to monitor and improve compliance, and strategy to maintain suggested health behaviors over time.