Compliance in the healthcare industry refers to the proactive measures taken within an organization to reduce the risk of fraudulent activity, unnecessary spending, or inappropriate patient care. A compliance program is an ongoing process that ensures that legal, ethical, and professional standards are met and communicated throughout an entire healthcare organization. This process is designed to protect patients’ safety and the integrity of the healthcare industry. Within a healthcare organization, a culture of compliance encourages participants to work toward preventing, detecting, and resolving activity that has the potential to lead to fraudulent activity, waste, or abuse. The basis of a culture of compliance is a well-organized plan that includes a series of steps, which are frequently referred to as compliance elements. The rules, industry regulations, and government legislation that pertain to the management of the company, employees, and consumers are described in depth in compliance policies. The Human Resources Policy, the Financial Services Policy, the Data Security Policy, and the Workplace Safety Policy are all part of the compliance policies.
Regarding audits and monitoring, compliance standards and procedures are necessary for finding and preventing code errors. Compliance monitoring is in place to guarantee that the company complies with the essential rules, regulations, policies, laws, and standards that direct the company. Without them, there are too many chances for unethical behavior and business practices. Companies can safeguard their brands from damage caused by scandals and legal action with the assistance of compliance policies. The responsibility of ensuring that an organization complies with internal and external regulations falls on the shoulders of the compliance department. Compliance departments in the financial services industry work hard to satisfy important regulatory objectives to safeguard investors and ensure that markets are fair, efficient, and transparent in their operations.
Law enforcement authorities in the healthcare industry, such as the Office of Inspector General (OIG), are responsible for monitoring and managing compliance with applicable regulations. The Office of the Inspector General is charged with several vital duties, one of the most important of which is to investigate potential violations of state and federal laws (Borgi & Mnif, 2021). The OIG will then pursue legal action against individuals who have broken state law. The OIG conducts reviews across several different audits that are carried out in order to find instances of such violations. In 2009, the Department of Justice (DOJ) and the Department of Health and Human Services collaborated to establish a second organization referred to as “HEAT,” which stands for the Health Care Fraud Prevention and Enforcement Action Team (HHS). Its primary purpose was to contribute to the reduction and eradication of Medicare fraud and abuse (Borgi & Mnif, 2021). HEAT’s tasks include collecting data and information from a variety of sources in order to combat fraud.
They advocate for “best practices” to reduce the number of people who abuse the Medicare system and commit fraud. They investigate any reports of fraudulent activity involving Medicare. All the experts believe that preventing fraud from occurring in the first place is the most efficient strategy to get rid of it. The HEAT task force and its partners have prioritized efforts to improve fraud prevention measures inside Medicare and Medicaid. It is one of the most critical areas of concentration for their work.
Controls such as auditing and monitoring are critical components for identifying, mitigating, and discouraging the occurrence of irregularities within an organization. The goal is to implement a process that uses external reviews to assist in identifying areas that require improvement while simultaneously ensuring that the processes currently in place are error-free (Borgi & Mnif, 2021). It is the responsibility of the Chief Compliance Officer (CCO) to take the appropriate steps to ensure that the final decision reached by the organization, which is based on the corrective actions, is not influenced by favoritism toward any particular employee working for the organization. Establishing a disciplinary committee tasked with the investigations and decision-making procedures is one of the relevant measures the CCO must take.
The question of how to approach continual audits and high-risk monitoring sectors presents compliance officers with a significant and persistent challenge. However, there is still a great deal of confusion regarding the distinction between auditing and monitoring and who is responsible for these functions (Stafford et al., 2018). This is even though the OIG has repeatedly emphasized the significance of auditing and monitoring activities in its various guidance documents.
The most significant thing that I have learned from putting policies into action is how crucial it is to break down every part of the job in order to get the best potential production from each person. It is essential to focus on the program’s structure, procedures, and results to accurately evaluate the coding compliance training program (Stafford et al., 2018). The structure is the amount of the program intended to prevent and uncover non-compliance with the law. The term “process” refers to the approach that the program will take in order to steer clear of such infractions.
In conclusion, procedures such as auditing and monitoring are critical components for identifying, mitigating, and discouraging the occurrence of abnormalities inside an organization. The goal is to implement a method that employs external reviews to assist in identifying areas that require improvement while guaranteeing that the procedures currently in place are error-free. Mechanisms for enforcement and disciplinary action promote effective accountability, reduce the probability of inappropriate behavior, and guarantee conformity with norms for public integrity. Fairness, objectivity, and timeliness are critical drivers for effective and transparent enforcement, and systems support them at all levels that facilitate cooperation and the exchange of information.
References
Borgi, H., & Mnif, Y. (2021). Compliance level with IFRS disclosure requirements across 12 African countries: Do enforcement mechanisms matter?Journal of Financial Regulation and Compliance, 30(1), 60–81. Web.
Stafford, T., Deitz, G., & Li, Y. (2018). The role of Internal Audit and user training in information security policy compliance. Managerial Auditing Journal, 33(4), 410–424. Web.