Practical Compliance Guidance for Health Care Governing Boards

"New forms of reimbursement (e.g., value based purchasing, bundling of services...) lead to new incentives and compliance risks," according to a recently released compliance resource for health care governing boards. The publication, issued by the U.S. Department of Health & Human Services, Office of Inspector General, in collaboration with the American Health Lawyers Association and other industry groups, provides practical tips for health care boards to promote effective oversight of compliance programs.

The guide covers board oversight of and engagement in: (1) the roles of, and relationships between, the health care organization’s audit, compliance and legal departments; (2) the process for reporting compliance issues within the organization; (3) the organization's approach to identifying regulatory risk; and (4) methods to promote enterprise-wide accountability for achievement of compliance goals and objectives.

While it recognizes that effective compliance programs must be tailored to the size and complexity of each organization, it nevertheless provides a series of general standards and practices that would apply to the board of any health care organization. In particular, the guide notes that boards should "[ask] the right questions of management to determine the adequacy and effectiveness of the organization's compliance program, as well as the performance of those who develop and execute that program, and... make compliance a responsibility for all levels of management."

In a rapidly changing health care environment, boards should expand their knowledge of "relevant and emerging regulatory risks, the functioning of the organization’s compliance program in the face of those risks, and the flow and elevation of reporting of potential issues and problems to senior management." These emerging risks include those associated with the market's increasing emphasis on quality, growing industry consolidation and changes in coverage (e.g., managed care) and reimbursement. Further, boards should strive to use newly available performance data to benchmark their organizations against their peers. In addition to assessing risks, monitoring the organization's response to those risks and assessing its performance, boards should ensure that management has established a process for investigating and responding to probable violations of law, including voluntary self-disclosure to the government.

Contact:  Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124.