What Does a Medical Compliance Officer Do?

According to MedTrainer, a health business company, a Healthcare Compliance Officer’s (HCO) job is to understand the laws, regulations, and medical standards that govern medical practices and any company that works in the healthcare profession. Every physician’s office, medical group, medspa, or any other healthcare provider – and any medical business – must understand what federal, state, and local laws and medical standards their healthcare company must follow.

Many healthcare practices and companies hire an individual person to serve as an HCO – either on a full-time or a part-time practice. Some healthcare practices and companies also have a compliance committee. HCOs should consult with an experienced healthcare lawyer who understands the applicable laws and advise healthcare businesses about the steps and options for coming into compliance.

What are the duties of a healthcare compliance officer?

HCOs help develop, implement, and review compliance protocols to help each member of the practice understand their legal and ethical obligations. A starting point for HCOs is to review, understand, and use the compliance program guidance provided by the Officer of Inspector General (OIG) for the US Department of Health and Human Services (US HHS). The OIG’s compliance program recommends that HCOs focus on the following seven compliance techniques:

• Written policies and procedures. Healthcare practices and companies should have written standards and policies that the members of the medical company should have, review, understand, and implement.
• Compliance leadership and oversight. The healthcare practice/company should appoint a lead healthcare compliance officer who has the responsibility for developing and maintaining a compliance program.  The lines of responsibility should be clear including who the HCO reports to – such as the managing partner or CEO. The HCO may be part of a compliance team.
• Training and education. The HCO should develop a program to train and educate each employee about their compliance requirements – from the head of the company and all the physicians to every healthcare provider and every administrative personnel.
• Quality lines of communication. Everyone who works for the healthcare practice should be able to report compliance violations or concerns without fear of retaliation.
• Compliance enforcement. The HCO and compliance team should create a process for investigating complaints and determining what disciplinary measures should be taken if there are violations.
• Risk assessment. The HCO should also implement a risk assessment program to determine where violations are most likely to occur and prioritize which violations have the most risk for the healthcare practice/company. For example, the HCO can establish monitoring and audit procedures to determine how well the practice/company is meeting its compliance requirements.
• Handling Violations. The HCO should work to respond quickly when compliance violations are discovered and take corrective measures.

The healthcare compliance officer also needs to address these compliance issues:

• Federal and state regulatory oversight issues
  • HIPAA. The Health Insurance Portability and Accountability Act. This laws prohibits the disclosure and issue of private healthcare information that is electronically submitted unless an exception applies or the patient gives their consent. HIPAA includes specific privacy and security requirements. States also have their own patient privacy laws.
  • Stark Law. Stark Law is a federal anti-referral law that prohibits physicians from referring Medicare and Medicaid patients to entities in which the physician (or an immediate family member) has a financial relationship in. The physician is supposed to refer patients based on the patient’s healthcare interests and not the physician’s financial interests. An experienced healthcare lawyer can explain what exceptions apply and how a managed service organization (MSO) can address some of the exceptions.
  • The Anti-Kickback Statute. This is another federal law that also prohibits referrals. Improper referrals that are based on any type of financial incentive given to the doctor to encourage the doctor to recommend the entity that gave the financial benefits for any medical services (such as a sham medical directorship or vacations to encourage a doctor to recommend prescription drugs made by the manufacturer). An experienced healthcare lawyer can explain what safe harbors apply. An MSO can help address these safe harbors.
  • The AKS applies to both the people providing, offering, and receiving the financial incentive. The law imposes criminal and civil liability.
  • The False Claims Act. This federal law prohibits the submission of false (fraudulent) bills to federal healthcare agencies such as Medicare, Medicaid, and TRICARE. The law also provides a financial incentive to the people who disclose financial fraud.
  • The corporate practice of medicine. Some states like California have laws to ensure that medical corporations are owned and managed by physicians and other licensed healthcare providers. Seasoned healthcare lawyers can explain how this law applies to your medical practice/business and what compliance strategies, such as a managed service organization (MSO) can be used to help ensure that the medical side of a medical practice and the business side are separated.
  • Many other medical and business compliance issues that an experienced healthcare lawyer can explain
• Appropriate medical standards. The HCO needs to sure that the healthcare providers who treat patients have the appropriate and current medical credentials according to the state and local medical boards where the providers practice. In addition to credential issues, the HCO needs to review other issues such as:
  • When and how doctors need to supervise the care any of their nurses or other staff members provide patients
  • The legal and medical requirements for telemedicine.
• Patient care. The HCO should help the medical staff understand the correct and improper way to market patients, the duty to keep the patient informed of various medical and legal issues, the duty to properly inform patients if a doctor is retiring or moving, and many other medical patient care matters.
• Responsibility for compliance. The HCO should review who is ultimately responsible for compliance issues within a medical practice (such as the lead physician) or a medical manufacturing business (such as the CEO). The HCO should address which compliance issues must be addressed for each employee and staff member within the company
• Billing compliance issues. Many of the risks for a healthcare practice involve the proper way to submit bills to governmental agencies such as Medicare, Medicaid, and TRICARE and to private insurers. The bills must be for services rendered. They must comply with Stark Law, the AKS, the federal False Claims Act, and any state billing laws. A skilled healthcare lawyer will review these compliance requirements to help ensure only legitimate bills are being submitted.

Qualifications of a Healthcare Compliance Officer

Some of the key qualifications of an HCO, according to MedTrainer include having the proper skills and experience, a strong belief in ensuring medical ethics, being able to solve problems, and familiarity with the relevant laws, regulations, and medical standards.

Generally, an HCO should have the following abilities and credentials:

• Education. A bachelor’s degree in healthcare administration – or a related field. Some practices/companies require a master’s degree in healthcare administration (or the equivalent). Certain certifications may also be required.
• Experience. The amount of experience an HCO needs varies depending on the size and scope of the medical practice and other factors. There are many different compliance issues. An HCO should have enough experience to work with an experienced healthcare compliance lawyer. An HCO should also be skilled with audits and investigations
• Leadership. A strong skill set including being able to communicate with employees, the leadership of the practice, and others. An HCO should be able to identify compliance problems and develop practice solutions. An HCO should also have leadership skills, pay attention to detail, and integrity.
• The ability to adjust. An HCO needs to work with a skilled healthcare lawyer to understand when new healthcare laws are passed and how those laws affect the medical practice or business. The HCO also needs to have strategies in place to promptly respond when an agency sends a warning letter or raises a complaint about a compliance issue, fraud, or a violation of any healthcare law or regulation.

It’s critical that a healthcare compliance officer understand that the goal of healthcare regulations is to ensure that the patient receives the best medical care possible. There are many federal and state regulations and state and local medical standards that every medical practice and medical business must understand. A skilled healthcare compliance officer should regularly work with an experienced healthcare lawyer to review the medical practice’s compliance requirements.

Doctors, medical practices, medical businesses, and other medical providers and companies should contact Cohen Healthcare Law Group, PC to review their legal and healthcare compliance requirements. Our experienced healthcare lawyers advise healthcare compliance officers and medical practices about compliance laws and regulations issues.