Healthcare Compliance and Ethics Program

Who Must Have and What is a Healthcare Compliance Program?

Various governmental regulations and acts require that all healthcare organizations and medical practices create, implement and maintain a site-specific fraud, waste and abuse healthcare compliance program. All healthcare organizations are vulnerable to pitfalls and should have a system set in place to monitor onsite behavior.

In the year of 2016 $3.3 billion was recovered by the federal government due to health care fraud, waste, and abuse. These pitfalls include but are not limited to patient neglect, misallocation of health resources, wrongful death, wrongful employment termination, failure to comply with health codes, and financial fraud.

A Healthcare Compliance Program is the development and use of internal controls to monitor adherence to applicable statutes, regulations, and Centers for Medicare and Medicaid Services Program requirements.

A Medical Professional Showing the Importance of a Healthcare Compliance Program

Our Healthcare Compliance Program

Med-Net Compliance, LLC works to educate and assist healthcare providers in meeting their obligation to establish and operate an effective fraud, waste and abuse compliance and ethics program.

We develop and implement a healthcare compliance and ethics program to help ensure the creation of a proactive, dynamic program structure to reduce the potential for fraud, waste and abuse and to put in place systems to identify and self-correct errors before the Medicare and Medicaid programs are billed.

Elements of Our Healthcare Compliance and Ethics Program

Healthcare Compliance Officer, Compliance Committee, and Governing Body
The Compliance Officer, with training and support from Med-Net Compliance, oversees the day-to-day management of the Compliance and Ethics Program.

Compliance Committee.
The Compliance Committee, led by Med-Net Compliance, steers the Compliance and Ethics Program.

Governing Body
The Governing Body, with counsel from the Compliance and Ethics Attorney, oversees the Compliance and Ethics Program.

Training and Education

Auditing and Monitoring.
A system for routine identification of compliance risk areas and self-evaluation of risk areas, including auditing & monitoring designed to detect criminal, civil and administrative violations.

Reporting System
Med-Net Compliance provides and operates a Hotline for all covered individuals to facilitate anonymous communication involving any Compliance and Ethics exposures without fear of retaliation or intimidation.

Response
Med-Net Compliance supports the Healthcare Compliance Officer in immediately responding to Compliance and Ethics exposures.

Enforcement of Standards
Med-Net Compliance supports the Healthcare Compliance Officer in appropriately counseling or disciplining covered individuals in accordance with Ethics and Healthcare Compliance  Program policies and procedures.

Reassessment/Reevaluation

Rapid Response Program©

The Rapid Response Program (RRP) is a unique component of Med-Net Compliance’s Healthcare Compliance Program. It offers Skilled Nursing Facilities (SNFs) a real-time triage to address a critical event such as, but not limited to, a fall with injury, elopement, unexpected death, or drug diversion and constitutes a good faith effort to minimize and mitigate risk to residents, employees, their families, the facility, and the community.

A Rapid Response Committee (RRC) convenes through teleconference or video conference when a critical event occurs.

Upon notification of a critical event, Med-Net Compliance will schedule a same-day call with facility management.

The RRC will collaborate with the facility and discuss the results of its investigation and its action plan.

Med-Net Compliance follows-up to ensure the facility’s action plan been implemented.

Healthcare Compliance and Ethics Acts and Governing Authorities:

Healthcare Fraud, Waste and Abuse Acts

Patient Protection and Affordable Care Act

False Claims Acts

Anti-Kickback Statute

Stark Physician Self-Referral Law

Deficit Reduction Act of 2005

Health Insurance Portability and Accountability Act

Health Information Technology for Economic and Clinical Health Act

Title VII of the Civil Rights Act of 1967 (Discrimination)

Governing Enforcement Authorities:

Healthcare Fraud, Waste & Abuse:

    • Office of Inspector General (Federal) and State Fraud Units (State)
    • Recovery Audit Contractors (RAC)
    • Zone Protection Integrity Contractors (ZPIC)
    • Centers for Medicare and Medicaid Services (CMS)
    • State Departments of Health (DOH)
    • Department of Justice

Privacy and Data Security:  Office of Civil Rights

Employment:

    • Equal Employment Opportunity Commission
    • Departments of Labor
      • Federal
      • State