Healthcare is a highly regulated industry and difficult to navigate legally. It’s best to contract with (or hire) someone who specializes in healthcare compliance to help you understand with which regulations your entity needs to comply, along with developing an internal compliance infrastructure and training. Make sure this professional has relevant experience, is properly certified, and is not on the Office of Inspector General (OIG) excluded individuals list (https://exclusions.oig.hhs.gov).

No. Lack of knowledge will not hold up in an investigation or audit. As a healthcare entity or individual, it’s your responsibility to keep up and comply with state and federal regulations. State or federal officials will hold that you should have known.

Employees working in various healthcare roles, including coding and billing, should be trained in appropriate areas (Documentation, Forms, Medical Necessity, Compliance Program Basics, etc.) immediately upon hire and at least annually thereafter. Employees should be trained when existing regulations change or are updated and when new regulations are put into place.

Above all, compliance is about healthcare organizations and professionals upholding their legal and ethical responsibilities. Efforts don’t go unrewarded, however. For example:

• A robust compliance program that includes on-going auditing can optimize billing and reimbursement.
• A good compliance program that cites patient care and outcomes as a priority facilitates quality reporting.
• A compliance program increases awareness within the entire organization, creates a team approach and environment, decreases errors and avoidable mistakes, and encourages employee communication.
• In the event of an audit, a well-designed compliance plan shows due diligence, which may lessen imposed fines or penalties for any wrongdoing.

Recommended resources include: OIG, the Centers for Medicare & Medicaid Services, the U.S. Department of Health & Human Services, and AAPC. These organizations provide informational articles, auditing software, news about updates and alerts, compliance ideas, and more.