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Why an Effective Compliance Plan is Necessary


The development of a compliance program is not only mandatory for medical practices; it is essential. A compliance program is an internal system implemented to identify and reduce risk, enforce government rules and regulations, prevent fraud, waste, and abuse, and promote quality care to patients It is more critical now than ever before for medical providers and practices to market themselves online. By implementing an effective compliance program, a practice can find and reduce billing errors, decrease the potential of an audit, improve payments, reduce potential fraud and abuse, and deliver high-quality care.

The importance of reducing fraud is high on the government’s radar, with recovered fraud and abuse totaling $2.6 billion in 2022, and over $13 billion in the last five years. As medical fraud rates steadily increase, healthcare providers will most likely see more governmental audits and investigations.

The Affordable Care Act has developed seven core elements for healthcare providers seeking to implement an effective compliance program:

  1. Implement written policies and compliance standards
  2. Compliance program oversight
  3. Efficient and effective training and education
  4. Conduct internal monitoring and auditing
  5. Open lines of communication with employees
  6. Auditing and monitoring
  7. Widely publicized, consistent, and timely discipline
  8. Corrective action- disciplinary action against responsible employees

Healthcare providers are now required to develop compliance programs under the Patient Protection and Affordable Care Act. A compliance program can assist you with identifying and correcting potential vulnerabilities in your practice. It can also help optimize claims payments, minimize billing mistakes, reduce the chances of an audit, avert protected health information (PHI) breaches, and avoid conflicts with Stark and other anti-kickback statutes. Practices that do not currently have a compliance plan should focus on these seven basic elements.

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This article contains general information only. Sunflower Bank is not, by means of this article, rendering accounting, financial, investment, legal, tax, or other professional advice or services. This article is not a substitute for such professional advice or services, before making any decisions related to these matters, you should consult a qualified professional advisor.