This will be similar to your current safety or infection control plan but will be tailored to the laws of fraud and abuse. It must include standards of conduct for employees, and ensure that areas such as ethical billing practice are included. In addition to your main plan there should be sub-plans for areas such as the laboratory and their unique approach to compliance. If you are JCAHO accredited, you must have a Code of Ethics. The problem is, most codes are in name only. Go back and review yours against the requirements of HCFA who insist that a code must be established and adhered to. Review the section on organizational ethics in JCAHO’s chapter on leadership.

Some care needs to be taken in developing a plan. Often an administrator such as the CFO mandates that something must be done. Usually this "knee-jerk" reaction is inadequate resulting in a focus on only one process such as upcoding. They make an attempt, the system fails and they look for a better way. After a few tries it occurs to them that this is a "team project" or "similar to quality improvement", the right people become involved, a team is formed and progress is made. A facilitator, trained in statistical tools and group dynamics, usually manages the team. They are usually a staff person from the quality improvement office who will often provide training and support for these positions.

Because of the accountability built into the federal law, each step of the compliance process must be measured. While all managers have been responsible for quality, risk and resource management their new responsibilities need to be clearly outlined and prioritized for them. The compliance planning law clearly states that every individual is responsible.

Many of the key players are already in place with systems up and ready to actively assist with the program. These are systems people, such as QM, UM, Case Managers and Risk Managers, to name a few. They are well versed in developing processes, and ensuring that they merge and end when appropriate. They can be instrumental in developing interfaces of processes which have historically never been together, For example, the MD who writes the orders and the clerk who processes the patient when they arrive for the test. The QM Office will usually be the first one to remember that there needs to be data supplied to validate where to begin the improvement process and documentation as evidence of compliance. Once the compliance plan is drafted, an assessment must follow which identifies which component of the compliance system needs fixing first. This is an area where data is essential. The QM Department can support two of the main features of the improvement process:

• the format for reporting
• methods and systems for tracking issues

Policies and procedures will need to be developed which promote the facilities commitment to compliance and that address specific areas of potential fraud, such as billing, marketing and claims processing.

 IMPLEMENTATION

Education and training programs will need to be developed and offered to all employees, subcontractors and vendors in order for you to comply with your plan and code of ethics. Education will need to be ongoing; when the program is installed, for new employee orientation, and as a mandatory yearly inservice. Everyone needs to know what ethics violations are and the method of reporting them. In addition to the general education program, there will need to be specific programs for core areas. For example, educational training in "Little Known Facts of Payment for all areas that post charges. Even with a computer program which catches the same patient using services within 72 hours and preventing duplication of billing, if the charges are delayed in posting, the computer is bypassed and multiple billing errors will occur.

The attorney overseeing the organization’s compliance progress will need to be involved for the same reasons peer review information goes to the medical staff, it protects it from disclosure.

Re-examine Medical Record Systems

Develop a sense of urgency and investigate and remediate all identified systemic and personnel problems immediately.

 EVALUATION

The evaluation phase focuses on how all the measures come together and are reported to the CEO. No one department can provide this, it must be a central service. The compliance officer may actually have their own staff. However, to bypass the existing systems in place in the QA department would be a gross misuse of funds and an extremely redundant system.

Utilize audits and/or other evaluation techniques to monitor compliance and ensure a reduction in identified problem areas. For example, components of this program could be to perform routine data collection and analysis of patient bills. This is really a quality control activity. But it is very likely that data analysis will indicate an opportunity to improve the way charges are sent, billing is handled, and fraud alerts are transmitted throughout the organization and elsewhere.

Supervisors are required to promote the program and adhere to compliance requirements as an element in performance appraisals. The compliance program includes a requirement for the discipline of supervisors who fail to detect an ethics violation in their subordinates.