Health care compliance programs have evolved since 1995 from a focus on Medicare billing rules to encompass all aspects of law and regulation pertaining to health care service delivery. Comprehensive compliance programs provide an infrastructure for clinical practice, including both patient care and business services. The purposes of a health care compliance program are to:
* Identify and analyze federal and state health care laws, regulations, rules, standards, and local policies and procedures.
* Establish and communicate policies and procedures that support legal and ethical businesses and clinical practices consistent with the organization's missions.
* Provide oversight and support services (compliance committee, compliance officers).
* Provide ongoing education and training for all levels of management and staff.
* Prevent, detect, and resolve legal, regulatory, and ethical issues within the organization in cooperation with legal, administrative, and operational personnel.
* Apply and enforce disciplinary guidelines to provide consequences for noncompliance.
* Audit, review, and monitor business and clinical functions and procedures, and provide recommendations to improve organizational performance.
Compliance programs reduce or prevent risk of civil or criminal liability by ensuring that health professionals and administrators adhere to standards for conducting the business of delivering health services. Net revenue can be increased by following precertification, registration, and admission/transfer rules; clinical standards; documentation requirements; and coding and billing rules. Compliance programs promote accuracy in all phases of the revenue cycle.
Over the past few years, patient care compliance has emerged as a focus of federal efforts to combat fraud and abuse. Patient care compliance encompasses issues related to quality assessment and improvement, utilization of services, health care outcomes, patient safety; and confidentiality of health information. This Forum addresses three primary components of patient care compliance: quality standards, confidentiality, and patient safety.
QUALITY OF CARE AS A COMPLIANCE ISSUE
The Department of Justice has used the False Claims Act (FCA) to support its contention that the care received in some skilled nursing facilities (SNFs) by beneficiaries of government-payer health care programs has been substandard. Findings included pressure sores, malnutrition, neglect of care, misuse of restraints, and poor medication use practices. Therefore, the health care providers were presenting "false claims" for payment because they did not deliver the required services.
The Centers for Medicare and Medicaid Services (CMS) publishes standards of care in Conditions of Participation, national coverage policies, and clinical guidelines. All of these documents are found at the CMS website: www.cms.hhs.gov. Other sources of quality standards include clinical guidelines published by the Agency for Health Care Research and Quality (ARRQ) (see www.ahrq.gov), Local Medical Review Policies (LMRPs), medical review guidelines, and other educational materials published by CMS fiscal intermediaries (FI) and programs offered by Quality Improvement Organizations (QIOs). Fifty-three Quality Improvement Organizations (formerly Peer Review Organizations) are CMS contractors whose mission is to ensure the quality, effectiveness, …