In an era of increased regulatory oversight, it’s critical that anesthesiology practices put programs in place to mitigate their risk.

“One of the best ways to protect your anesthesiology practice from Health Information Portability and Accountability Act violations or any other regulatory violation is to put in place a compliance program,” says Courtney Reasoner, Compliance Program Director for Anesthesia and Pain Management at McKesson. Reasoner refers to the seven elements of an effective compliance program, as provided by the Office of the Inspector General1 along with one additional element.

  1. Develop compliance policies and procedures
    Policies and procedures are the heart of any compliance program, and they should be developed around specific risk areas. For a program to be successful, you need to clearly define appropriate procedures and protocols for those areas that represent the most significant risk.
  2. Designate a compliance officer
    Select an individual within your department and assign them primary responsibility for overseeing the creation, implementation and operation of the initiative. This individual should be trustworthy, respected and have enough authority to ensure proper implementation and execution of the program. 
  3. Conduct education and training programs
    Creating training and educational initiatives for employees is critical. These should include comprehensive training for new and existing employees, as well as specialized curriculum for unique job roles. 
  4. Conduct internal monitoring and reviews
    You can track or monitor the efficacy of a compliance program by assessing documentation and work processes. It’s also a good idea to conduct a preliminary or baseline audit before the compliance program is initiated to better understand specific risk areas and vulnerabilities. 
  5. Enforce disciplinary standards through well publicized guidelines
    Make sure your compliance program has clear policies that outline specific consequences for employees who fail to meet or adhere to defined standards or procedures. Disciplinary programs should be progressive in nature and be linked to appropriate remedies.
  6. Develop open lines of communication
    An important way to build commitment to the program is to create channels of communication that allow employees and others to easily convey regulatory concerns without fear of penalty or retaliation. You might consider an anonymous hotline as a way to implement this.
  7. Respond appropriately to detected misconduct
    With rules and standards there must be consequences and those consequences should be levied consistently regardless of the employee’s stature within the organization. Should an employee violate these rules, the appropriate disciplinary action should be enacted on a timely basis.
  8. Conduct annual risk assessment
    Each year you should conduct a strategic and operational risk assessment to ensure that your compliance program continues to address risk factors that are specific to the emergency medicine industry. These changes may be the result of new laws, regulations or governmental policies and procedures.

https://oig.hhs.gov/compliance/compliance-guidance/index.asp

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About the author

Mary Jo Gross, CPC, CANPC of Compliance – Anesthesia and Pain Management, McKesson Business Performance Services