Breaking Compliance News Blog

Swiss Cheese Compliance

Posted by Margaret Scavotto, JD, CHC on 11/8/18 7:40 AM

Find me on:

Fire to fire. Blind spots. Whack-a-mole. Don't know what I don't know.

every compliance program has holes

These are common phrases used by compliance officers to describe their compliance efforts - particularly new ones. The truth is, every compliance program has holes.

The successful ones know where their gaps are, and have a plan to fix them.

How do you find your compliance gaps?

You will find some gaps by performing routine audits of your compliance risk areas, like HIPAA walk-throughs and medical necessity documentation reviews.

By diligently monitoring your compliance hotline and seeking feedback from your staff, you will identify even more gaps.

To discover the rest, you will need to conduct a gap analysis - also known as a compliance risk assessment, baseline assessment, or annual review.

Assessing your program

Divide your review into three pieces:

  1. Review the seven compliance program elements (policies, auditing, training, communication, compliance officer & committee, disciplinary action, and investigations/corrective action)
  2. Evaluate each compliance risk area (like HIPAA, billing, kickbacks, records, employee screening, etc.)
  3. Analyze any data you have. Your data could include your PEPPER report, hotline call statistics, employee survey results, percentage of employees who completed compliance training, etc.

Keep the following goals in mind:

  1. Verify that compliance tasks are completed. Example: Verify that your Compliance Committee met at least four times this year.
  2. PROVE that the task was completed. Example: Locate Compliance Committee meetings meetings, agendas and attendance sheets.
  3. Make sure you can provide this proof immediately if the OIG shows up and is waiting patiently in the next room.
  4. For every compliance task, goal or requirement you evaluate, identify strengths and weaknesses - and establish a game plan for the future.

If you need help finding your gaps

The HCCA/OIG Compliance Effectiveness Roundtable document is an excellent resource for compliance program review, and is available here. This document lists examples of questions to ask when evaluating your compliance program. 

Or, let MPA assess your program and give you an action plan to fill your compliance gaps and maximize compliance.

Know your gaps? Close them with MPA's compliance and HIPAA tools.

MCS Signature November 2018

compliance store button

Topics: Auditing and Monitoring

    Privacy Policy           Terms of Use