Healthcare Compliance

Healthcare providers in all settings implement compliance programs in order to ensure ethical business practices in accordance with compliance program guidance from the Department of Health and Human Services Office of the Inspector General (OIG). This is necessary due to the increased severity of penalties established by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (public law 104-191) and the Balanced Budget Act of 1997 (public law 105-33). By ensuring ethical business practices through compliance programs, healthcare providers reduce their risk of criminal and civil litigation.

For example, providers must follow the requirements for issuing advanced beneficiary notices (ABNs):

CMS Beneficiary Notice Initiative

Under the Medicare Fee-for-Service (FFS) and Medicare Advantage (MA) Programs, Medicare beneficiaries and providers have certain rights and protections related to financial liability. As of March 1, 2009, FFS providers, physicians, practitioners, and suppliers are required to use the revised ABN, Form CMS-R-131. The revised ABN manual instructions are available from the download section of CMS's FFS Revised ABN page.

Federal government monitoring activities include:

Comprehensive Error Rate Testing (CERT) Program

The CERT program was established by the Centers for Medicare and Medicaid Services (CMS) to monitor and report the accuracy of Medicare fee-for-service (FFS) payments. The CERT program measures the error rate for claims submitted to Carriers, Durable Medical Equipment Regional Carriers (DMERCs), and Fiscal Intermediaries (FIs). Read more about CERT on the CMS Web site.

Office of the Inspector General (OIG)

The OIG is a division of the Department of Health and Human Services (DHHS) that investigates issues of noncompliance in the Medicare and Medicaid programs (including fraud and abuse). The OIG is overseen by the Department of Justice. It is through this office that the federal government has established compliance plans for the healthcare industry. Read more about the OIG on their official Web site.

In the late 1990s the OIG began promoting voluntary compliance programs for the healthcare industry. The OIG issued voluntary compliance program guidance to assist healthcare entities to develop effective internal controls that promote adherence to applicable federal and state law and the program requirements of federal, state, and private health plans. The OIG believes the adoption and implementation of voluntary compliance programs significantly advances the prevention of fraud, abuse, and waste in healthcare. The OIG issued sample compliance programs for multiple types of healthcare entities. These sample compliance programs provide details on specific elements each healthcare entity should consider when developing and implementing an effective compliance program. Visit the OIG’s compliance guidance Web pages for more information.