Healthcare compliance

Healthcare compliance is the formal name given to proactive tasks to prevent fraud, waste, or abuse within a healthcare entity. A compliance program is the active, ongoing process to ensure that legal, ethical, and professional standards are met and communicated throughout the entire healthcare organization.

Compliance promotes a culture where participants within the healthcare organization strive to prevent, detect, and resolve activity that could lead to fraud, waste, or abuse. The foundation of compliance culture is an organized plan with steps often referred to as compliance elements. The terms ethics, culture, and code of conduct are woven together in many documents that discuss compliance.

Advantages of Healthcare Compliance Programs
Healthcare compliance is needed to ensure that healthcare organizations protect federal, state, and commercial insurance dollars from being misused. Organizations also benefit from having a healthcare compliance plan and program. An effective compliance program helps the organization detect issues early so the organization can fix them, such as medical coding and billing problems. The compliance program also sets a positive tone for the organization, indicating that its leadership and employees care about compliance and want to act ethically.

Healthcare organizations cannot reap the benefits of their compliance programs unless they use them. Having a healthcare compliance program designed to be window dressing, meaning the program was never intended to be as it was portrayed on paper, can cause many problems. For instance, if an organization is investigated for issues related to healthcare compliance — and the issues identified were spelled out in the organization’s compliance plan — the investigator will ask the organization to explain why it understood the core elements of compliance when designing the plan but chose to ignore its own plan.