Health Care Compliance: What You Need to Know

IN A NUTSHELL:

• Health care compliance more strict than other industries
• Regulations, standards, and laws set at state and federal level
• Violations can result in fines, lawsuits, or loss of licenses

Compliance in health care is the standards of adherence to regulations, rules, and laws with respect to industry practices. However, a majority of compliance issues relates to patient safety, privacy of information, and billing practices in order to provide a high level of care and ensure smooth operations.

The gravity of health care compliance is much greater than other industries. Health care organizations are held to strict regulations, standards, and laws at state and federal levels. A violation of compliance can result in large fines, lawsuits, or the loss of licenses.

The Office of Inspector General (OIG) helps health care providers and facilities comply with relevant laws and regulations. The OIG has compliance resources, which are often tailored to particular providers. A key component of the OIG’s mission, along with the Department of Health and Human Services, is to detect and root out fraud in Federal health care programs, including Medicare and Medicaid. Members of the pubic are able to report fraud on the OIG website.

Other compliance laws and organizations:

• The Social Security Act governs funding and requirements for Medicare, Medicaid, the Children’s Health Insurance Program, and more.
• The Health Information Technology for Economic and Clinical Health (HITECH) Act as well as The Health Insurance Portability and Accountability Act (HIPAA) protect patient privacy by requiring health care organizations to implement safety measures to keep patient records secure.
• The Drug Enforcement Administration and The Food and Drug Administration oversee the creation and distribution of medication.
• The False Claims Act, originally passed by Congress in 1863, makes it illegal to file a false claim for funds from a federal program. The law has been amended several times over the years to deal with military spending and government health care programs.
• The Patient Protection and Affordable Care Act, often known as simply The Affordable Care Act or referred to as “Obamacare”, implemented new requirements for health insurance, Medicaid, and more.

The Joint Commission:

The Joint Commission on Accreditation of Healthcare Organizations is an independent, nonprofit organization established in 1951 to evaluate health care organizations that voluntarily seek accreditation. The Joint Commission evaluates and accredits thousands of health care organizations in the United States, including hospitals, home care entities, and other health care organizations that provide behavioral health care, laboratory, ambulatory care, and long-term care services. The Joint Commission also evaluates and accredits health plans and health care networks.

Joint Commission surveyors visit accredited organizations a minimum of once every 36 months, and two years for laboratories, to evaluate standards compliance by conducting a survey. The surveyors are highly trained. Health care industry experts who are doctors, nurses, hospital administrators, laboratory medical technologists, and other industry professionals.

During the survey, patients are randomly selected, and their medical records are used as a roadmap to evaluate standards compliance. As surveyors trace a patient’s experience in a health care organization, they talk to the doctors, nurses, and other staff who interacted with the patient. Surveyors also observe doctors and nurses providing care and speak to the patients themselves.

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