7 Elements of an Effective Compliance Program

Posted on 23 Oct, 2017 |comments_icon 5|By Elizabeth

The HHS OIG released compliance guidelines for most healthcare sectors between 1998 and 2008. During this period, the watchdog agency developed “The Seven Elements of an Effective Compliance Program.” Now, almost 20 years later, these elements remain effective for evaluating the state of your practice’s compliance program. Ask yourself the following questions to determine if you have the seven compliance protocols in place:

Question 1: Have you implemented written policies and procedures?

Your practice should have a written compliance plan that you review annually and revise if necessary. Don’t have a written compliance plan? Then you have some work to do.

If you’re feeling ambitious, you may want to try authoring your compliance plan’s first draft using these components as the document’s skeleton—and then fill in the details for your practice. Experts caution, though, that you shouldn’t go it alone from start to finish.

Work with an attorney: Enlist the help of your practice’s attorney during the compliance plan drafting process. Getting a legal expert’s input and final approval will ensure you haven’t overlooked important elements.

Hire a consultant: You can hire a healthcare management consulting firm specializing in compliance plans to write your compliance plan or to offer legal advice. The more specialized your practice is and the more ancillary services you offer, the more help you’ll need to make sure your compliance plan covers all your liability areas, says Curtis J. Udell, CPAR, CPC, CMPA, senior advisor with Healthcare Advisors Inc. in Annandale, Va.

Even though the cost may be a deterrent, hiring a consultant to handle your compliance plan can save you valuable time, as well as costs associated with breaches and violations.

Contact your specialty society: If your practice belongs to a healthcare specialty society, this may be an excellent resource to tap into. Societies may have customized templates and other data useful for creating a specialty-specific compliance plan.

Avoid cookie-cutter compliance. At all costs, you should avoid downloading or purchasing a cookie-cutter compliance plan that only requires you to fill in the blanks with a few practice details, advises Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J.

If your compliance plan isn’t customized to address the unique details of your office’s billing practices, the document will not be a useful source of guidance. A cookie-cutter plan quickly purchased and stuffed on the shelf won’t help you prove your commitment to compliance.

Question 2: Have you designated a compliance officer and compliance committee?

Physicians are ultimately responsible for what is billed under their provider numbers, though they typically will designate an employee(s) to perform the day-to-day compliance responsibilities.

The designated compliance officer will:

  • Coordinate the annual compliance in-service with the physician in charge of compliance
  • Oversee the practice’s compliance program and recommend changes to office policies and procedures as needed
  • Coordinate and participate in education activities
  • Take charge of investigating incident reports
  • Coordinate communication with the billing department or billing service when billing, coding, or compliance problems occur
  • Oversee the internal monitoring process

It may be appropriate for a practice to outsource compliance officer responsibilities. The outside individual or group must develop and maintain a good working relationship with the practice and stay up-to-date with office activities and changes. The OIG recommends that the practice designate an internal employee to serve as a liaison with the outsource compliance officer.

Question 3: Have you conducted effective training and education?

Make sure you document all training efforts, whether conducted one-on-one or in groups. Include conferences, webinars, publications, and other continuing education activities you provide for your staff. Many practices keep an appendix alongside their compliance plan to document training activities.

Question 4: Have you developed effective lines of communication?

Everyone in the practice should know they may voice their compliance concerns without fear of retribution. They should be encouraged to report these concerns to their supervisor or your practice’s compliance committee and get feedback on the problem’s resolution.

Question 5. Do you conduct internal monitoring and auditing?

Make sure the audit routine described in your compliance plan matches what you actually do. If you have an aggressive audit plan that reviews 30 dates of service per physician, and you consistently audit only 10, you should amend your compliance plan. It’s important to do what you say you’re going to do.

Question 6. Do you enforce standards through well-publicized disciplinary guidelines?

For your compliance program to be effective, you need clear consequences for staff behaviors that run counter to good compliance. The OIG advises that you spell out the consequences of non-compliant behavior during orientations, in written employee manuals, and in staff trainings. Keep a copy of your disciplinary policies in your compliance plan.

Question 7. Do you respond promptly to detected problems and undertake corrective action?

You can’t run a good compliance program if you stick your head in the sand. Investigating a potential problem may be the last thing you want to do as a busy practice administrator, but you must protect your practice. That’s why you should have a compliance committee. Clinicians and staff need to support one another to address potential compliance trouble quickly and thoroughly. If corrective action means seeking outside help, such as an auditor or an attorney, do so.

Responsibility for compliance risk and mitigation begins and ends with you—and is crucial to the success of your medical practice.

For more help, pick up a copy of The Physician Practice Compliance Sourcebook, a comprehensive resource that will help you to implement proactive protocols and take charge of all aspects of risk management.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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