Case Study:

Corporate Compliance Program at a Rural Hospital


The Circumstances and Challenges

The Corporate Compliance Program was in trouble! A small rural district hospital was faced with a crisis in its compliance activities and compliance staff.

The hospital undertook a review of its Corporate Compliance Program addressing specifically fair market value and commercial reasonableness of the Hospital’s agreements with physicians. In addition, urgent attention was needed to deal with the Compliance Manual, the Compliance Committee, audit and monitoring activities, Compliance Policies related to specific risk areas, Code of Ethical Conduct, and HIPAA.  A number of weaknesses and a lack of compliance with regulatory standards were discovered.  Some required legal counsel involvement.

Compliace Program

The Change and Selection of a Consulting Firm

A decision was made to eliminate the current CCO position and utilize an outside consultant to revitalize the Corporate Compliance Program. The CEO and the Board of the hospital asked The Fox Group, LLC, Consultants to the Healthcare Industry, to address, manage, and handle many different, but related Corporate Compliance Program challenges. Because of circumstances and regulatory deadlines, The Fox Group was given two days to get started. Some aspects of consulting assistants were time-critical and involved legal counsel, already at work for the hospital.

The Solution, Outcome, and Sustainability

Quick revitalizing of the Corporate Compliance Program was necessary, including conducting audit and monitoring activities, development of policies, procedures, and many other required compliance items.  Almost immediately, The Fox Group started assisting legal counsel, consolidated the Compliance Officer Duties, and provided ongoing consultation and training for the hospital’s staff, both on-site and via virtual meetings.

Many Corporate Compliance Program activities were completed within a few months. Sustainability was assured, by The Fox Group implementing its recommendations. As a result, Compliance activities were maintained, such as investigations, adoption of the hospital’s and OIG Workplan, and establishing and managing a hotline.  Chairing the monthly Corporate Compliance Committee, regularly meeting with the Board of Directors, providing reports, and addressing current issues, making recommendations, and assuring approvals by the Board, resulted in ongoing adherence to the Corporate Compliance Program, and provided regular updates.  Sustainability is assured.

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