Changes to the Compliance and Ethics Program Could Impact the Private Healthcare Community

Compliance and Ethics Program changes could impact private healthcare communityIn 2000 and 2008, the Office of the Inspector General initiated and supplemented compliance program guidance to engage the private health care community and curb fraud and abuse in areas of quality, employee performance, financial waste, and legal risks and liability. Now, in 2013 the Center of Medicare and Medicaid announced their intention to propose regulations to implement section 6102 of the Affordable Care Act, the compliance and ethics program.

The Center of Medicare and Medicaid has not announced a release date for implementation, but it should be announced on the next Unified Agenda. This agenda outlines a timeline for regulatory priorities that are under development. According to the Center for Medicare and Medicaid, the statute speaks for itself, but they will not be enforcing this requirement until regulations are enacted.  

So what does this mean for senior living and assisted living facilities? If the Office of the Inspector General investigates a healthcare organization for possible fraud before the new compliance and ethics program regulations go into place, they can use absence of a facility plan to show that the provider does not take their obligations seriously. Creating a facility plan is important, regardless if the Center for Medicare and Medicaid enforces it, because the law went into effect on March 23, 2013.

In the near future, Medicare and Medicaid payments will be based on payment for quality outcomes instead of the number of procedures and tests as it is now, according to the Office of the Inspector General. The Center of Medicare and Medicaid, through the Office of the Inspector General, is encouraging all long term care organizations to establish and maintain effective compliance programs with the goal to improve the quality of care and services. The risk for not developing a comprehensive compliance program is to become a target of governmental investigation and potential penalties.

As a provider, you still have time to develop a compliance program and demonstrate a good faith effort to comply with the applicable statues.  The Affordable Care Act grants strict preference to alternative payment methods if the healthcare organization delivers quality care with efficiency and lower costs. This can lead to savings in healthcare dollars and greater reimbursement for quality care if healthcare organizations meet reporting deadlines and take reform efforts seriously. The need to complete a compliance program is significant.

Looking for help developing a compliance program? AssuredPartners NL CORE Solutions will work with you to make sure that your organization is on the right track. Our team of clinical risk management professionals has worked with long term care organizations on compliance programs for more than 16 years and can create a customized plan, no matter if you’re just starting out or already on the path to compliance. To learn more or to contact an agent, visit: Clinical Risk Management.

*Information from The Center for Medicare and Medicaid, the Accountable Care Act section 6102, and the Office of the Inspector General

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