Bass, Berry & Sims attorneys Justin Brown, Dee Harleston, Brianna Powell and Morgan Tandy outlined ways healthcare organizations can manage fraud and abuse risks through effective compliance programs in an article for the American Health Law Association’s (AHLA) Health Law Connections magazine. In the article, the authors briefly trace compliance program guidance from the United States Sentencing Guidelines (USSG) to Office of Inspector General’s (OIG) recently published General Compliance Program Guidance (GCPG), provide an overview of the GCPG, and offer suggestions on designing and operating compliance programs.

The OIG published the GCPG in November 2023 “which summarizes key federal health care laws, describes the seven-element compliance program infrastructure (including adaptations for small and large entities), offers other compliance considerations, and catalogs OIG compliance and legal resources. Along the way, the GCPG offers practical tips and valuable insights.” The authors outline several key aspects of the GCPG, including:

  • Acknowledging that compliance programs should be shaped by entities’ size and resources, the GCPG also provides suggestions for right-sizing compliance programs for both small and large organizations.
  • Consistent with DOJ’s increased emphasis on financial incentives, the GCPG addresses how ownership and payment incentives can affect compliance.
  • Although quality and patient safety are often treated separately from compliance, OIG stresses that organizations should incorporate quality and patient safety oversight into their compliance programs.
  • The GCPG reminds participants that even though legal counsel may be involved at the outset of structuring and documenting an arrangement, there should be ongoing monitoring of compliance with the terms and conditions of the arrangement.

The attorneys examine in detail the following overarching principles of an effective compliance program:

  • The foundation of an effective compliance program is a commitment to compliance throughout all facets of the organization.
  • The program should be fundamentally risk-based.
  • The program should generally be built on the seven elements of an effective compliance program.

In conclusion, the attorneys said “Compliance programs play a vital role in managing fraud and abuse risks. If appropriately designed and implemented, they can reduce both the likelihood of noncompliance and the costs of noncompliance should it occur.”

The full article, “Managing Fraud and Abuse Risks Through Effective Compliance Programs,” was published in the January 2024 edition of AHLA’s Health Law Connections magazine and is also available online (subscription required).