Healthcare Industry: Compliance Program and Investigations

In the current scenario of the world, with so many frauds happening in each and every industry, the health industry is not left behind, as there are so many fraudsters who do not leave anyone not even in a crucial industry like health, which is related to the life and death of an individual. To avoid such a situation and to stay away from such frauds, the government has initiated a Health Compliance Program and to take care of such programs and to avoid all frauds we have Medicaid Investigations.

This compliance program helps by continuously following the process of adhering to the legal, ethical and professional standards maintained by the healthcare institutions and providers. And the officers assigned to take care of such compliance by checking on the cases against possible frauds, abuse, waste, and other potential liability areas by protecting the organizations.

Fraud related to the healthcare industry includes filing the wrong documents in order to make more money from the client. In many cases, the healthcare companies ask the customers to get more investigations done so that they can make more money, make fake prescriptions to get false treatments. That is where the Compliance Program of these Healthcare companies comes into action.

There are different elements of a compliance program which are as follows- Implementing written policies, procedures, and standard of conduct, Assigning a compliance officer, providing effective training and education to the officers to understand the procedure and detect the fraud cases, developing effective lines of communication, conducting internal monitoring and auditing, enforcing standards through disciplinary guidelines and responding immediately to detect offenses and taking correct measures to avoid it.

There are many certificates also that Healthcare Compliance the company gets to ensure the authenticity and recognitions like companies that are Certified in Healthcare Compliance (CHC), a certificate for Professional In Healthcare Risk Management (CPHRM), the certificate for Healthcare Financial Professional (CFHP), Revenue Cycle Executive certificate (CRCE) etc.

Healthcare Compliance Program affects every type of healthcare provider and organization from an individual to the largest global healthcare institutions. The main idea to start this program is to improve the quality and availability of healthcare while also controlling the cost. The Healthcare government of any country is responsible for the compliance of the program and for any consequences if caused due to the lack of compliance. The entire organization formed to follow such a program is responsible for any mishappening.

There are appropriate Medicaid officers who take care of such Compliance Programs to keep in action, to keep on such activities there is Medicaid Investigations. The way these investigations work is to keep a check and doing audits regularly by identifying overpayments and reducing the payment of inappropriate Medicaid claims. These activities and audits work on a post-payment basis, and claims can be crossed check up to 3 years after the case was filed. Those individuals who receive a large amount of Medicaid payments are also to be audited and if something caught, a fine or penalty can be added by the Medicaid program. These audits take place by reviewing all the documents that one submits to claim for Medicaid.