Purpose and Overview
The governing board and the administration at SNHU Medical Clinic are committed to delivering quality and sustainable patient care; guided by exceptional ethical standards, professional and /or business stature as well as uncompromised compliance with every detail in the applicable state and federal laws that regulate the delivery and cost of healthcare. These include the rules that forbid fraud, deliberate abuse as well as wastage of resources channeled purposely for healthcare.
This compliance draft and its component policies or procedures are intended to reinforce a culture with SNHU that facilitates quality and efficient patient care in the prevention, detection, and resolution of professional conduct which fail to conform to the judicial provisions. Principally, the draft provides all the elements that can be taken up as references in deterring conduct within SNHU premises or its jurisdictional confines that do not conform to the law and healthcare program or payment requirements. The elements described herein apply to all personnel at SNHU Medical Clinic alike. Collectively, the SNHU Medical Clinic personnel include, but not limited to, employees, volunteers, healthcare practitioners, and affiliated entities that deliver their services on behalf of the clinic. The elements are highlighted in sections hereafter:
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Drafted policies, procedures, and standards that promote SNHU Medical Clinic’s commitment to the applicable regulations and laws from the outside governing bodies.
The designated Compliance Officer and Committee bound by responsibly to implement and monitor the compliance program
A system for receiving complaints about any arising compliance violations, and the procedures to uphold anonymity of the complainants to the highest degree of discreetness possible. So as to protect them from retaliatory approaches from the violators.
Periodic audits and other mechanism laid down to oversee the smooth functioning of the compliance program
A restoration procedure for investigating and offering resolutions to any identified challenges.
Medical requirements for laboratory and diagnostic procedures
Policy and Procedures
Policies and procedures are the primary guides for all the activities taking place in and around SNHU. Without them, the leadership would be lacking grounds for correcting errors and other malpractices within the organization ( Giannangelo, 2019) .
Compliance Procedure
Ethics and professionalism: The SNHU personnel must align their service performance with high ethical guidelines and professional standards of the organization. They are under institution to treat their colleagues, clients, seniors, and subordinates with the utmost respect in all manner of professionalism. They shall embrace honesty, fairness, integrity, and respect.
SNHU policies and procedures: The personnel shall comply with every applicable workplace procedures and policies, not just those provided in this draft of compliance.
Requirements, Laws, and Regulations: SNHU personnel must comply with all federal laws and state laws and directions or other third-party requirements that pertain to the delivery of quality and indiscriminate healthcare.
Non-discrimination: SNHU personnel must maintain equal perspectives on personnel they encounter along their lines of service. They shall not discriminate against their co-workers, colleagues, patients, and any other service persons along their lines of duty on the grounds of sex, color, race, age, religion, nationality, ancestry, sexual orientation, or disability.
Induced referrals: The SNHU personnel must not fall short of the federal and state laws recommendation against receiving payments or other items of value to induce referral or specialized patient care (Fix et al., 2018; Giannangelo, 2019) .
Improper inducements to medical beneficiaries: Any inducement to Medicaid, Medicare, or other government beneficiaries may be susceptible to violations of applicable law. The SNHU personnel must not be involved in waivers or discounted deals on government beneficiary co-pays without first ascertaining that the discounts or waivers are done in compliance with SNHU’s charity care policy
Improper billing: The personnel must not engage in improper or fraudulent billing of medical expenses and other questionable financial inducements. They must not bill for services that were not rendered, sign forms for a physician with authorization, alter medical records improperly, and submit duplicate billing for the same service ( Giannangelo, 2019) .
Governing Board Responsibilities
It is important for the board to ensure that the SNHU runs on an effective compliance program. This provides them with a platform to follow up on the members of SNHU and for taking appropriate actions that ensure the utmost delivery of patient care.
Compliance Procedure
They must be the first to observe and comply with the compliance program before enforcing it.
They must appoint appropriate personnel to the compliance committee, starting by the complainant officer.
They must permit reasonable or appropriate funding that will implement the compliance program, especially to the compliance committee staff, to enable them to reform their duties without unnecessary financial constraints.
Receive and make reviews of compliance from the compliance committee on a quarterly basis or as frequently as deemed possible by the members of the board.
They shall take appropriate action on issues pertaining to compliance that may be brought before them by the committee
Take part in periodic training of the relevant compliance programs set forth for education and enhancing of the SNHU personnel skills
Advocate for and take the lead in upholding continentality on the compliance issue brought before them by the SNHU personnel
Communication Regarding Compliance Issues
Upholding smooth communication between SNHU personnel and the compliance officers or appropriate authorities ensures positive execution of the compliance program and reduces the likelihood for fraud, abuse, or waste (Joudaki et al., 2018). No personnel must, therefore, be subject to disciplinary action or other forms of retribution for acting in good faith by reporting under the compliance program.
Compliance Procedure
Questions: SNHU personnel is at liberty to seek clarification from the compliance authorities if they have unanswered questions on the applicability of the law, regulations, or third-party requirements such as those from the payor program. The questioning process should be made in an official, documented format in adherence to the requirements of the authorities and in a manner that reflects professionalism
Reports of suspected violations: The SNHU personnel shall report actions that appear suspicious or are outright violations of the compliance program or any law, regulation, or third-party requirements. These reports must be made within the shortest possible deadlines to minimize the chances of alteration of evidence or coercive confrontations from violators looking to subvert the course of justice.
Preservation of confidentiality: The SNHU will work hard to ensure that the identities of the person reporting the case of violations are kept confidential. However, SNHU may not guarantee that the information shared will remain confidential, especially if the report extends to government authorities.
Non-retaliation: No SNHU personnel who make a report of suspected violations will be held responsible for their actions by the violators and the board alike. Therefore, they will not be subject to any retaliation or retribution whether or not the allegations are grounds, especially if the report was made in good faith.
Auditing and Monitoring
It is appropriate for SNHU to implement a self-assessment program that will monitor and evaluate the feasibility of the compliance program. The findings from the monitoring program are useful in coining better strategies to enhance the compliance practices at the clinic (Weske et al., 2018).
Compliance Procedure
Departmental Responsibilities: The compliance office must establish appropriate policies that monitor every department’s compliance with the needs and risks surrounding its functionality.
Methods: The compliance officer will liaise with the departmental head to make periodic reviews of the departmental practices that are relevant to compliance. These included but not limited to, payment claims, contracts, advertising, gifts and inducements, necessity, quality, and propriety of the care being rendered, and receipt of the response.
Frequency of response: The frequency of response and the extent of monitoring at SMHU will depend on the needs of the potential compliance issues and violations.
Reports: Departmental complaints will be provided at least once every year to make comprehensive reviews of compliance issues. These reports should include, but not limited to: descriptions of the department's ongoing auditing activities and the results of the audits., a description of the compliance issues identified, the resolutions to the concerns, and a description of the training provided to prevent further recurrences.
Medical Requirements for Laboratory and Diagnostic Procedures
Medical requirements are primary vital factors that determine the ordering of tests and the completion of diagnostic procedures ( Giannangelo, 2019) . They inform the physicians’ responsibilities. Thus, it is essential to review the procedures in the compliance draft to ensure proper utilization of the medical facilities available at NHSU. The compliance draft will, therefore, become a disciplinary guide for the medical staff who get involved in instances of inappropriate use of diagnostics or laboratory procedures and testing.
Compliance Procedure
The laboratory and diagnostic procedures will be carried out under the instruction of an appropriate physician order.
All outpatient tests will be accompanied by narrative diagnosis codes.
All tests must be done following individual orders unless the tests are a part of a validated multi-channel test series.
Tests ascribed to Medicare reimbursement and other government beneficiaries must be carried out only after they are considered necessary for diagnosis or treatments but not merely for screening purposes.
References
Fix, G. M., VanDeusen Lukas, C., Bolton, R. E., Hill, J. N., Mueller, N., LaVela, S. L., & Bokhour, B. G. (2018). Patient-centered care is a way of doing things: How healthcare employees conceptualize patient-centered care . Health Expectations, 21 (1), 300–307.
Giannangelo, K. (2019). Healthcare code sets, clinical terminologies, and classification systems . Chicago, IL, ISBN: 978-1-58426-673-0: American Health Information Management Association.
Joudaki, H., Rashidian, A., Minaei-Bidgoli, B., Mahmoodi, M., Geraili, B., Nasiri, M., & Arab, M. (2016). Improving fraud and abuse detection in general physician claims: A data mining study. International Journal of Health Policy and Management , 5(3), 165–172.
Weske, U., Boselie, P., van Rensen, E., & Schneider, M. (2018). Using regulatory enforcement theory to explain compliance with quality and patient safety regulations: the case of internal audits. BMC Health Services Research , 18 (1), 62.
