A Guide to Healthcare Compliance Regulations

January 17, 2023

It is no news that as a trillion-dollar industry saddled with the responsibility of patient care, the healthcare industry is one of the most regulated industries in the United States. This justifies the rapid growth in healthcare compliance within the industry. 

The Bureau of Labor and Statistics projects that compliance officer jobs will grow by over 8 percent from 2016 to 2026.

To effectively address ever-evolving healthcare compliance regulations placed by governing bodies, you need to employ compliance professionals and even institute a compliance committee within your healthcare facility. 

What Is Healthcare Compliance? 

Healthcare compliance is an ongoing process concerned with meeting and exceeding professional, legal, and ethical standards set by relevant authorities in healthcare. As a result of the nature of the healthcare industry, following rules is everything. 

In healthcare, Compliance standards are voluminous and dynamic, I.e., ever-changing and improving. The frequent changes in these rules require operational and workflow changes, internal audits, ongoing educations, health IT compliance updates, etc. 

Regulatory compliance requires that your healthcare facility (regardless of the size) develops effective modes of operations, structures, and procedures to enforce appropriate conduct, ensure administrative staff is trained, and adhere to the policies set by compliance entities. 

When you take health compliance seriously within your healthcare organization and uphold it as a culture from top to bottom, it will become difficult for government authorities to detect compliance violations and sanction your healthcare facility. 

Ultimately, the primary purpose of healthcare compliance is to improve patient care. When appropriate clinical standards are being adhered to, the quality of patient care will improve, complication rates will reduce while avoiding the cost of government sanctions and penalties.  

Who Regulates Healthcare Compliance? 

Today, several federal and state agencies regulate healthcare compliance in various categories such as patient information privacy, ensuring quality care, combating fraud, and protecting healthcare staff. Some leading compliance regulators are stated below;

  •  The Food and Drug Administration (FDA) and the Drug Enforcement Administration (FDA): regulate the safe production and distribution of Medication. They also ensure the safety of medical and biological devices.
  •  The Department of Health and Human Services (HHS) and the Inspector General (OIG): Perform routine audits on healthcare organizations to reduce waste, fraud, and misappropriation of healthcare funds. The OIG publishes a Work plan to announce certain aspects it intends to focus on every year. This will give your organization a heads-up on possible types of audits you could face for the year. 
  •  The Joint Commission (TJC): They perform accreditation exercises to certify that your healthcare organization adheres to specific compliance standards for patient safety and quality care.
  •  Medicaid Fraud Control Units (MFCU): They probe and prosecute fraudulent activities by Medicaid providers. They also ensure that patients are neither abused nor neglected within healthcare facilities. Depending on the size of your medical facility, it makes sense to set up an internal fraud control team to ensure compliance under the False Claims Acts and avoid MFCU prosecution.
  •  The Occupational Safety and Health Administration (OSHA): They operate within the US Department of Labor and help implement workplace safety compliance standards. They have a multi-step compliance process that handles everything that has to do with the safety of your health workers while in the workplace. 

The National Association for Health Quality also (NAHQ) also performs the function of TJC save that its primary focus is credentialing verification organizations and insurance plans. 

The Centers for Medicare and Medicaid Services (CMS) and other insurance panels have also brought about quality initiatives to foster high-quality healthcare through accountability. 

Some Examples of Healthcare Regulations

There are so many regulations that healthcare organizations must adhere to, but some of the most important ones are listed below; 

  • The Health Information Portability and Accountability Act (HIPAA) was written in 1996 and implemented in 2003. The act enforces standards and policies protecting patients' medical information protection and confidentiality. 
  • The Social Security Act caters to funding and requirements for Medicare and Medicaid.
  • The False Claim Act: This Act was enacted to make providers filing a false claim to a federal payer an illegal activity.
  • The Physician Self-Referral Law (Stark Law): The provisions of this law forbids physicians from referring patients with Medicare or Medicaid to an entity (like Pharmaceutical Companies) with whom the physician has affiliations. 

Some Ideas For Creating an Effective Healthcare Compliance Program 

Among other ways to implement an effective healthcare compliance program in your organization, creating a culture of compliance within the facility is crucial. This means making the whole point of the compliance standards ingrained into the core of your organization's mode of conduct. 

Based on the OIG's compliance guidelines, an effective compliance program must do the following; 

  •  Develop, distribute, and enforce written policies and codes of conduct. 
  •  Institute a compliance committee and appoint a chief compliance officer. 
  •  Conduct frequent training on written policies and new compliance requirements.
  •  Give enough room for communication and make it possible for all employees to report their concerns anonymously.
  •  Access and measure compliance by carrying out internal audits and reviews.
  •  Have well communicated disciplinary actions for non-compliance within your facility
  •  Be proactive and respond promptly to violations by developing corrective action plans. 

Following this guideline will make it easy to run your healthcare facility without fear of possible violations; you will also develop a solid reputation for your facility, consequently improving your patient retention rate. 

Always remember that a compliant organization is a safe one, a confident one, and an empowered one.

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