Michael Gerber wrote a book about being an entrepreneur called “The E Myth” in which he emphasized the importance of working “on” the business and not just “in” the business. The point of his recommendation is that often, when we are deeply embroiled in the day-to-day operation of the business, we often lose sight of the bigger objective. The same holds true for the compliance program. The world of health care moves very fast with laws and regulations seeming to change nearly daily. In an ever changing regulatory landscape it is easy to take action to meet one new regulation and not consider how that action may impact a requirement for another part of the organization.
When it comes to the compliance program it is essential that all the pieces work together to fight bad activity, and that the program contain all the essential elements in order to be effective in detecting and deterring fraud, waste and abuse. If the organization never takes the time to step back and take a more global view (working on the program rather than working in the program) it is very possible the effectiveness of the program can be compromised. The absolute best way to achieve that global view of the compliance program is to conduct a program effectiveness evaluation.
Evaluating a compliance program through the lens of effectiveness (detecting and deterring fraud, waste and abuse as well as protecting and securing PHI) allows the organization the opportunity to know where there may be holes in the program, which can happen for any number of reasons, including a changing regulatory environment. Identifying the holes or areas of weakness provides the basis for the annual Work Plan and allocation of resources for the coming year.
There is no one way to conduct a solid program effectiveness evaluation. Organizations can conduct the evaluation in-house using readily available resources and checklists such as the Department of Justice, Criminal Division, Fraud Section, Evaluation of Corporate Compliance Programs guidance document released in 2017, or the New York Office of Medicaid Inspector General, Compliance Program Review Guidance. One caveat to conducting a self-evaluation, just like when we look at ourselves in the mirror, what we see is not always an accurate picture of our true selves.
Many organizations feel having an outside party who is well versed in the elements of an effective compliance program provides a more accurate picture of how the program functions on an ongoing basis, and where the program may be “soft”. Typically an outside evaluator will turn over more rocks, so to speak, in an effort to determine effectiveness which increases the validity of the findings.
Regardless of whether your organization decides to conduct a program effectiveness evaluation in-house or hire an outside consultant to handle the evaluation, the key is to carefully review the findings, and take appropriate action to close any holes in order to enhance the effectiveness of the program. Taking the time to work “on” the compliance program will pay huge dividends in terms of the effectiveness of the program which means fewer things going bump in the night!
Most business leaders get frustrated when employees don’t do the right thing. You shouldn’t have to convince people to do what is right. MCA builds a compliance program and a culture where employees to the right thing, the right way, at the right time so you can focus on taking care of the people you serve.
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Midwest Compliance Associates