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Healthcare Compliance Requirements

New healthcare compliance requirements interest physicianThe requirement for an effective compliance program for healthcare organizations is transitioning from voluntary to mandatory, with the requirement in the Patient Protection and Affordable Care Act (PPACA) in 2010 that healthcare providers applying to enroll as Medicare providers have a compliance program in place.

One of the keys to a compliance program is to make it truly effective.  It must be more than a document initially adopted by the governing body and reviewed once per year.  The Office of Inspector General (OIG) of the federal Department of Health and Human Services (HHS) recommends specifics about the components of a compliance program.

Healthcare compliance program & HIPAA requirements:

  • Conducting internal monitoring and auditing
  • Developing and implementing compliance program policies and procedures
  • Designating a compliance officer or contact person
  • Conducting appropriate training and education of staff
  • Responding appropriately to detected offenses and developing corrective action
  • Developing open lines of communication, and
  • Enforcing disciplinary standards through well-publicized guidelines.

The Fox Group recommends that some additional areas (listed below) be addressed in a healthcare compliance plan because their integration will shore up an organization’s ability to best integrate the federal requirements in a more systemic manner that will make adherence to required areas more manageable.

Compliance program policies and procedures should cover areas such as:

  • Evaluation of compliance risk areas
  • Hiring practices
  • Healthcare insurance and billing compliance
  • Medical records releases and informed consents
  • Professional courtesy discounts for services
  • Diagnosis and procedure coding for medical services
  • Medical necessity and documentation
  • Business and medical records retention
  • Confidentiality
  • Patient rights
  • Employee safety, rights and obligations, and
  • Environmental concerns

Each healthcare organization also needs a Code of Ethical Conduct, setting forth the expectations for all staff members for ethical conduct within the organization.

A healthcare compliance plan consultant able to assist with all facets of a compliance program

Why Risk Based Coding, Read Now!

The Fox Group is uniquely qualified to assist medical practices and other healthcare organizations with developing and implementing compliance program policies and procedures.  In addition to documentation of the program, The Fox Group has staff qualified to conduct a coding and documentation audit and other types of audits integral to an effective compliance program.

A few healthcare organizations find themselves implementing compliance activities required by a Corporate Integrity Agreement (CIA).  A corporate integrity agreement requires the same elements recommended for voluntary compliance programs, but makes them mandatory, with annual reporting, for the healthcare organization.  Most CIA’s also require some mandatory auditing by an outside entity referred to as an Independent Review Organization,or “IRO”.  The Fox Group provides IRO services, and can help with other healthcare compliance consulting such as program development, employee training and annual reporting.


“…it is apparent that you have a wide experience in the very things we need to know.”

Dr. A. F., Health Education
Huguley Memorial Hospital,
Mountain healthcare, Inc.

Fort Worth, Texas


Excellence since 1989

The Fox Group was founded in 1989 and has provided outstanding healthcare consulting and executive management services to domestic and international clients throughout the United States and Europe.


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