Avoiding a Compliance Nightmare in 2020

Why This Topic Matters

The article helps readers understand the kinds of compliance-program elements that government agencies and payors expect to see, which is relevant to reducing organizational risk and responding to audits or investigations.

Article Sections

1. Opening perspective on compliance program design

   Introduces the article’s overall theme: common compliance-program mistakes and the importance of practical, organization-specific policies and procedures. It frames the discussion in terms of health care compliance risk and program effectiveness.

2. Early-2020 compliance and audit pressures

   Describes recent examples of enforcement, audit activity, and payer actions affecting health care organizations. It emphasizes the operational areas that can create exposure when compliance processes are weak or unclear.

3. CMS and payor expectations for compliance programs

   Discusses how compliance-program expectations relate to participation requirements, forms, and requests for proof of compliance efforts. It focuses on the significance of documented organizational readiness.

4. DOJ guidance on evaluating corporate compliance programs

   Summarizes the U.S. Department of Justice framework used by prosecutors to assess compliance programs. The section highlights the three overarching evaluation questions and the major topic areas that follow.

5. Twelve compliance topics prosecutors consider

   Walks through the principal categories of compliance-program review, including design, communication, reporting, third parties, management commitment, resources, discipline, testing, investigations, and remediation. The discussion is broad and organizational rather than code-specific.

6. Common mistakes and the limits of generic templates

   Explains why one-size-fits-all compliance templates may be inadequate without organizational review and customization. It contrasts generic documents with tailored policies and a gap-analysis approach.

7. Closing caution for providers and organizations

   Concludes with a warning about the potential consequences of poor compliance preparation and the importance of not ignoring regulatory risk. It closes by reinforcing the article’s preventive message.