(EDITOR’S NOTE: Jenny O’Brien is one of YouCompli’s Titans of Compliance. As part of her “Next Jen” series, she contributes posts that help the next generation of compliance leaders learn skills, attributes, and other characteristics to succeed in their careers. It’s all part of her commitment to developing both the compliance profession and individual compliance professionals. For more posts by Jenny O’Brien, visit her Author Page.) 

In my last article “I Got the Compliance Job, Now What?” our focus was tips and tricks to help you bring value and be relevant to your new team. In this article, the focus shifts from the individual to how your compliance program and team bring value and are relevant to the goals and priorities of your organization. 

The Parallel Path of a Compliance Program 

Truly effective compliance programs have a strategic vision supported by a business plan that is communicated to C-suite leaders. The plan should encompass a comprehensive roadmap that takes it down two distinct but equally critical paths. The first is to ensure regulatory requirements are met, and the second is to demonstrate awareness and alignment with key business priorities. Ultimately, supporting both results in compliance being a key partner around the organization and achieving its business priorities and goals. 

Meeting Regulatory Expectations/Requirements 

A compliance program exists quite simply because it is mandatory for organizations that accept funding from Medicare, Medicaid, and other federal government programs. To participate, organizations must demonstrate there are processes in place to prevent, detect, and correct regulatory issues. The framework of the seven elements of a compliance program is established by the Federal Sentencing Guidelines and other state and federal regulations. All of these were recently detailed by the OIG’s General Compliance Program Guidance (GCPG); even though this is voluntary, it signals regulators’ expectations if/when your program is audited.  

At its core, demonstrating to the regulators that you have a framework for the seven elements of an effective compliance program is a fundamental reason an organization invests in a compliance program. However, limiting your compliance program’s impact to this singular purpose is shortchanging both your program and your organization. 

Compliance’s Value Proposition to Your Organization 

The second, and (I would posit) even more critical role your compliance department should play for your organization, is to demonstrate the value-add of a compliance department beyond satisfying regulatory requirements.  Examples include: 

• Aligning with Business Priorities: Embedding your team into each operational area allows for awareness and input early in the process, and for compliance to serve as strategic advisors and proactively support implementing business priorities.  
• Scaling for Growth: The compliance team needs to understand key business priorities so they can be part of the solution and respond to business needs. This requires hiring talent that can be flexible and nimble in supporting new areas of growth and emerging risk issues. 
• Prioritizing Consumer-Centric Focus: So much of any organization’s focus is on organic growth and ensuring retention of current customers and/or patients. Compliance aligns well with others around the business committed to providing high quality, operational excellence, and a zero-defect mindset. 

Bottom line: rather than limiting the breadth and scope of your compliance program to what is minimally required by regulators, think of the breadth and scope of what it should be. As I mentioned in my last article, you should be building relationships with business partners to better understand their priorities. This enables you to think strategically, be innovative, and bring ideas and solutions that are proactive rather than reactive. Now that is a quantifiable value proposition! 

Jenny O’Brien, JD, MS, CHC is president and principal at BlackBridge Advisors. She has been the chief compliance officer (CCO) at multiple companies, including UnitedHealthcare, as well as a state assistant attorney general and a partner at a law firm. She is a past president and board member of HCCA/SCCE, serves on the boards of Bon Secours Mercy Health System and St. Charles Health System, and the advisory boards of Stellar Health and YouCompli. 

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27 Ungated Resources for Compliance Leaders and Teams 

Compliance professionals sometimes feel undervalued in comparison to other functions in their organization. They think leaders and colleagues don’t really understand what they do.  

These resources will help. Packed with ideas, tips and recommendations, these pieces were written by professionals with many years of compliance experience. 

You can quickly skim for articles that relate to your needs and interests. Bookmark this page as a reference for future questions or projects.

Visit Now

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The post Next Jen: The Value of Compliance Programs and Teams  first appeared on YouCompli.

(EDITOR’S NOTE: Jenny O’Brien is one of YouCompli’s Titans of Compliance. As part of her “Next Jen” series, she contributes posts that help the next generation of compliance leaders learn skills, attributes and other characteristics to succeed in their careers. It’s all part of her commitment to developing both the compliance profession and individual compliance professionals. For more posts by Jenny O’Brien, visit the YouCompli Blog.) 

When I interviewed for my first compliance role 20+ years ago, I have to admit I really didn’t understand what the job involved. I was coming from the lens of a practicing attorney, which I’m sure many of you understand can be somewhat narrow! Like many of you, in preparing for that interview, my research included the “seven elements” and other more technical aspects of the role.   

I soon learned the role of a compliance professional was much broader. It was more about working in the business with operations teams to support implementing regulations than reading and interpreting regulations. I especially enjoyed the opportunity to partner with business leaders across all functions, as we shared the goal of finding strategic and innovative solutions to challenging issues and preventing issues upstream. Suddenly, the role was much more interesting, and it also made me realize there were skillsets I needed to develop to become more effective. 

Maybe you’re transitioning into a Compliance role from legal, quality or some other operations role. Or maybe you’re fortunate enough to be hired into an entry level compliance role. Either way, here are a few tips and tricks to help you bring value and be relevant to your new team.  

1. Understand the Role of Compliance vs. Legal 

The question about the difference between legal and compliance is common. It’s important that you understand your role and be able to articulate how compliance and legal roles are separate and distinct functions. Here’s the difference: 

• Legal: This function is accountable for interpreting laws and regulations and providing legal advice which the compliance team then uses to work with the business to “operationalize.” In addition to other legal work, such as contract review and transactions, the legal team focuses on managing litigation and generally protecting the organization’s interests. 

• Compliance: This function ensures the organization has processes in place to adhere to laws, regulations, and internal policies. Compliance is accountable for developing a strategy to prevent, detect, and correct issues and supporting accountable business leaders in implementing that strategy.  

Another way of thinking about it: legal is accountable and focused on “doing what’s legal,” and compliance can help by ensuring discussions gets escalated to “doing what’s right.” That being said, a strong partnership exists between the two teams, and they are often closely aligned, coordinated and working together on various initiatives.  

2. Become a Compliance Expert 

There are many tools and resources to support you in developing your “Compliance IQ.”  This effort never ends, and is one I continue to invest in through being involved with the HCCA (Health Care Compliance Association) and from networking, mentoring, compliance certification courses, and overall best practices and benchmarking. No matter how experienced you are in compliance, the recently released General Compliance Program Guidance from the Office of Inspector General (OIG) is a great starting point and excellent roadmap for compliance professionals. 

3. Develop Your Soft Skills 

If you enjoy rolling up your sleeves and solving problems, you chose the right job. A day in the life of a compliance professional, whether you’re entry-level or running the compliance team, is about developing relationships with operations leaders and their teams across all areas of the organization. It’s also about helping them solve problems and implement solutions that fix identified issues. As you continue to build your hard skills and compliance expertise, it is also important to develop your soft skills. 

During that first interview of mine, the interviewer told me, “I need someone who can build relationships, is strategic and innovative, and can influence up, down, and across the organization.”  I never forgot that, and used that as my roadmap in building my skillset to be a more effective compliance professional. It’s still my guide as I continue to find new ways to grow in my role today. I challenge you to test yourself and do the same! 

Jenny O’Brien, JD, MS, CHC is president and principal at BlackBridge Advisors. She has been the chief compliance officer (CCO) at multiple companies, including UnitedHealthcare, as well as a state assistant attorney general and a partner at a law firm. She is a past president and board member of HCCA/SCCE, serves on the boards of Bon Secours Mercy Health System and St. Charles Health System, and the advisory boards of Stellar Health and YouCompli. 

Qualified compliance professionals do the heavy lifting for you, simplifying regulatory change management    

Our in-house team works tirelessly to monitor US regulators, carefully read the regulations in their entirety, and translate the information into simple regulatory intelligence you can use. We deliver model procedures and expert tools that can be used to fulfill your business requirements. Everything is validated by a third-party law firm. Follow the button below to get a tour of our healthcare compliance software.  

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The post I Got the Compliance Job! Now What?  first appeared on YouCompli.

I recently attended the 2024 Health Care Compliance Association (HCCA) Managed Care Conference, and it was great to attend sessions and network with professionals and exhibitors from across the country. If I received $1 for every time artificial intelligence (“AI”) was referenced, I might have the financial means to invest in one of the many AI products being pitched to the health care industry.  

There was a lot of sharing of ideas around how to respond to both the opportunities and challenges that AI brings to our organizations and industry. I can summarize these in three themes – the ABC’s, if you will, of integrating AI into your compliance strategy. 

1. (A)SSESS

Great organizational compliance programs feature a formal process to assess and prioritize risk. This must include AI, because it can impact every part of our business – from clinical care delivery, claims payment, and patient interactions to human resources, procurement, and accounting. That said, AI is the same as any other emerging risk facing our organizations.  

If not already part of your 2024 compliance plan, “AI Program Oversight Strategy” should be at the top of your list. Key focus areas to include as part of the program strategy include: 

• AI Inventory: Assess and capture current AI initiatives within the organization in preparation of building an intake process to capture and review future AI initiatives.  
• AI Governance Strategy: Work with key business partners to build an oversight structure to help ensure consistency and standardization as new AI is proposed and introduced into the organization.  
• AI Awareness: Integrate AI into annual education and training modules. This will ensure awareness about protecting data and safeguards required when using AI in a healthcare setting, as well as capture key state and federal regulatory considerations. 

 2. (B)UY-IN

As interest in and adoption of AI increases, the value proposition in adopting and articulating an enterprise-wide AI strategy increases. The ability to use AI to optimize innovation of care models, increase patient access, scale, grow services and market share, and reduce the cost of healthcare is exciting and transformative.  

As with any enterprise initiative, the following considerations should be at the top of the list: 

• Executive Champion: Building an AI culture starts at the top, which is why recommending that your organization identify an executive business leader and champion is essential. Who that should be will be unique to each organization and dependent upon their strategy. The compliance professional’s role will be to ensure they are one of the key stakeholders at the table. 
• Skillset/Expertise: You also need the right skillset within the organization and your compliance team to lead this work. Do you have the right mix of talent and expertise within your team to help you adapt to and support your organization’s strategy of optimizing AI to scale and grow? Hiring new people, or an inability to hire, can’t always be the answer. It’s our job as compliance professionals to continue to find different ways to work to support emerging risk areas.  

3. (C)OLLABORATION

Generative AI is impacting all areas of healthcare. As adoption increases, so can the risks. Be prepared for an oversight structure that includes new partnerships such as cloud vendors, external IT professionals, and other consulting firms. If not already at the table, be ready to deploy the same due diligence and compliance program oversight as part of your vendor oversight initiatives. 

Integrating an AI program oversight structure can be viewed in two ways: overwhelming and fragmented, or reframed into something as simple as “ABC.” By taking a practical approach to this complex topic, you will be viewed positively by your team and able to respond well to questions about AI risks from your business partners, the C-suite, and your Board of Directors. 

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Jenny O’Brien, JD, MS, CHC serves on the advisory board for YouCompli. She is also president and principal at BlackBridge Advisors. She has been the chief compliance officer (CCO) at multiple companies, including UnitedHealthcare, as well as a state assistant attorney general and a partner at a law firm. She is a past president and board member of HCCA/SCCE, serves on the boards of Bon Secours Mercy Health System and St. Charles Health System, and the advisory board of Stellar Health. 

Qualified compliance professionals do the heavy lifting for you, simplifying regulatory change management    

Our in-house team works tirelessly to monitor US regulators, carefully read the regulations in their entirety, and translate the information into simple regulatory intelligence you can use. We deliver model procedures and expert tools that can be used to fulfill your business requirements. Everything is validated by a third-party law firm. Follow the button below to get a tour of our healthcare compliance software.  

Get the latest from healthcare compliance experts   

Never miss an article by Jenny O’Brien. Sign up for YouCompli’s weekly email if you haven’t already.    

The post The ABC’s of Integrating AI Into Your Compliance Strategy  first appeared on YouCompli.

I always find it energizing to look back at the past year, and shift focus to what sits at the top of the risk list for the upcoming year. Here are some best practices and tips for both! 

Insights and Feedback from 2023 

Before moving on from 2023, it is important to take time and get feedback from business partners to ensure an “outside-in” perspective is included in your 2024 plan. A simple and effective approach is to survey key stakeholders by asking, “How has the compliance team been most effective and valuable to you?” This helps recognize and celebrate successes as well as validate what is working well and what work should continue. It is also critical to follow up with: “How can our team be even more effective and valuable to you?” By doing this, you will gain unique insights that could strengthen your program. 

Strategically Prioritizing Risks for 2024 and Beyond 

In addition to capturing the core elements of an effective compliance program, the most strategic part of plan development involves the work the team does to identify and prioritize emerging risks. There are three areas that support moving from a reactive to a proactive compliance program.    

1. Optimizing Regulatory Guidance – State and federal regulators are providing more clarity around expectations and signaling where they will focus their resources. There are two key sources of these items:   

• The U.S. Department of Justice’s (see https://www.justice.gov/criminal/criminal-fraud/page/file/937501) Criminal Division released the Evaluation of Corporate Compliance Program document in March 2023 to assist prosecutors in evaluating a corporate compliance program as part of their investigation. 
  • Compliance teams should review the document and assess how their program measures up to expectations. Any gaps identified should be reviewed by leadership and the Board of Directors as appropriate. This will ensure awareness and enable preparation for any known risks related to three fundamental questions that will be asked of the organization: 
    • Is the corporation’s compliance program well designed? 
    • Is the program being applied earnestly and in good faith? 
    • Does the corporation’s compliance program work in practice? 
• The Office of Inspector General’s (see https://oig.hhs.gov/compliance/compliance-guidance/) new General Compliance Program Guidance document, released in November 2023, provides helpful information around relevant federal laws and other resources.  
  • Compliance teams should recognize and utilize the GCPG for insights around regulator expectations that are included in the tips, definitions, and FAQs. It is also an excellent resource to use when developing and refreshing content for employee and/or Board orientation. 

2. Aligning with 2024 Business Priorities – It’s the compliance team’s responsibility to understand and awareness of the organization’s 2024 business goals and priorities. This serves two purposes: to signal to your business partners that priorities are aligned and to better position compliance to anticipate and support emerging operations risks.    

As part of the ongoing development of your compliance team, focus on business acumen as much as developing technical compliance skills. This is accomplished by encouraging all team members to read leadership messages, attending business updates, and listening to how compliance can better support business imperatives. If you are a public company, listen to earnings calls and investor meetings to better understand how the company performed and performance commitments for future growth. Team members at all levels, from entry level to experienced managers, will benefit from becoming more astute business leaders as they also focus on developing compliance skillsets.  

3. Understanding Industry Trends – As a leader in the organization and the expert on regulatory and compliance issues and trends, it is important for you to stay current on industry news. This means investing time in publications, websites, and blogs on what is happening across the industry. C-suite colleagues, Board members and other key stakeholders are looking to you for help prioritizing and identifying emerging risks that you will find by doing so. 

It may help to create a cross-functional group to review and assess emerging risks. Examples to consider for 2024 include:  

• Artificial Intelligence (AI) and Investments in Data Analytics 
• New Partnerships (Private Equity and Strategic Investors)  
• Outsourced Services (IT, Revenue Cycle) 
• Financial Stress and Operating Margins 
• ESG and Sustainability 
• Politics and Impact on the Regulatory Trends 

As we pause to strategize and prioritize, the good news is there is no shortage of advice, regulatory guidance, and opinions about what to consider including in our compliance plans. That said, keep in mind that more is not necessarily better. In fact, it is essential that we be disciplined and bring strategic insight into what NOT to include as well. This will ensure a systemic and realistic approach to mitigating and prioritizing the key risks for our organizations. 

Jenny O’Brien, JD, MS, CHC serves on the advisory board for YouCompli. She is also president and principal at BlackBridge Advisors. She has been the chief compliance officer (CCO) at multiple companies, including UnitedHealthcare, as well as a state assistant attorney general and a partner at a law firm. She is a past president and board member of HCCA/SCCE, serves on the boards of Bon Secours Mercy Health System and St. Charles Health System, and the advisory board of Stellar Health. 

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The post Ready, Set, Go! Identifying Emerging Risks in Your Annual Compliance Workplan  first appeared on YouCompli.

Did you ever play “Hot Potato” as a kid? It was one of my favorite games back in the day, and my classmates and I always used to play at recess.  

For those not familiar, Hot Potato is a game or term that dates back to the mid-1800s and involves tossing a hot potato around a circle at a furious pace. If you drop it, you’re out of the game – and the last one standing wins.  

Nowadays, it often comes to mind as a useful way of thinking about challenging issues that come up in compliance work. Similar to literally tossing a hot potato around a circle, we often toss complicated problems around our organizations as we look for practical and quick solutions. And just as Hot Potato requires quick reactions, great hand/eye coordination, and the ability to handle the heat if you want to stay in the game, we also need these skills to be effective and successful in our compliance role. 

Among your business partners and colleagues, you may notice many of the same personalities that you might have seen on the playground. Some of them might look to pass the hot potato onto the compliance team and think their work is done. Fortunately for most of us, this type of conduct is the exception.  

In most instances, we see the best intentions and behaviors come out when we pull our circles of cross-functional leaders together to strategize and solve complex compliance issues. In my experience, when we identify all the key stakeholders, ensure they’re at the table, and clarify their roles in remediating issues, the collective quickly focuses on figuring out how NOT to drop the hot potato. Instead, collaborative teamwork, innovation, creativity, an alignment of goals and priorities, and faster resolution of issues emerge. 

As you continue the great work you do to prevent, detect, and correct issues on non-compliance for your organization, keep embracing and catching the hot potatoes that come your way. After all, that’s a sign that we’ve already accomplished one key step: supporting our employees in raising issues and getting them into the right hands. There is nobody better than us to support our business partners in navigating through challenging issues! 

Jenny O’Brien, JD, MS, CHC serves on the advisory board for YouCompli. She is also president and principal at BlackBridge Advisors. She has been the chief compliance officer (CCO) at multiple companies, including UnitedHealthcare, as well as a state assistant attorney general and a partner at a law firm. She is a past president and board member of HCCA/SCCE, serves on the boards of Bon Secours Mercy Health System and St. Charles Health System, and the advisory board of Stellar Health. 

Qualified compliance professionals do the heavy lifting for you, simplifying regulatory change management    

Our in-house team works tirelessly to monitor US regulators, carefully read the regulations in their entirety, and translate the information into simple regulatory intelligence you can use. We deliver model procedures and expert tools that can be used to fulfill your business requirements. Everything is validated by a third-party law firm. Follow the button below to get a tour of our healthcare compliance software.  

Get the latest from healthcare compliance experts   

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The post Why Compliance is Like a Game of Hot Potato  first appeared on YouCompli.

I’ve had the privilege of leading and being part of compliance teams at non-profit providers, for profit payors, start-ups, and regulators. Regardless of the business model, there’s been one common reason why these organizations were successful in “operationalizing” their compliance programs: compliance priorities were aligned with business objectives and priorities. And the operations leaders bought in. 

Compliance’s Guiding Principle  

In our compliance role, we can help business partners accountable for operations across all areas of the organization prevent and mitigate risk. As we work with them to develop the framework of a compliance program, and then execute on it, we should follow a key guiding principle: develop a compliance strategy for structures, processes, and outcomes supported by and aligned with accountable business owners. This will ensure coordinated operational execution and ownership that delivers on our regulatory commitments. 

A first step in getting to operational buy-in and alignment is to identify and assign an accountable business owner to each compliance issue. If you are unclear who owns operations for an area (e.g., clinical, revenue cycle, patient safety/quality, information technology, marketing, human resources, etc.), look across the executive leadership team to identify who you would need to partner with to remediate matters. This is a critical component of the intake process when assessing a compliance issue, regardless of whether it comes to you via a hotline, your own monitoring, results of an audit, or a risk assessment. These matters and issues are related to operations, and they’ve become compliance issues due to a misinterpretation of regulation during implementation, a process error due to lack of education or training, or simply human error. As a result, our business partners need to be at the table collaborating on potential operations solutions that get to the most effective and efficient solution.   

Working with Accountable Executive Owners 

Once you have an executive owner for the issue, the next step is to work with them to identify who on their leadership team will be accountable for working with your team to create and operationalize a pragmatic and effective remediation plan. This demonstrates alignment from the top down and clearly signals this work is a priority to managers and front-line team members. It also results in minimizing the chance for “swirl” that sometimes occurs when compliance teams struggle to get traction with their business partners when executing on corrective action plans. 

There are times that I have brought a “compliance issue” to the executive leadership team where there are multiple or cross-functional accountable leaders at the table. In these situations, there hasn’t been just one owner – or we’ve discovered a gap where there isn’t an identified leader. For example, we had a credentialing issue with a complex regulation that was not being executed within operations well or even getting the attention by the business team that was needed for sustainable remediation. When the matter was brought to the leadership team, we discovered three leaders were accountable and each owned a part of the remediation – but none saw themselves as responsible for the overall outcome. This is not unusual, especially on more complex regulations or system and policy implementations.  

In these instances, it is even more important to stop and have the discussion about who should lead this initiative. To be clear, this does not release the other two “involved” business owners from holding their teams accountable to deliver on their portion of responsibility. However, assigning a primary executive owner clarifies for both the CEO and Chief Compliance Officer (CCO) who is accountable for breaking down barriers if challenges arise in remediation and meeting regulatory obligations and commitments.  

The opportunity to be embedded and integrated into operational teams across the organization is such a key part in delivering on the commitments of our compliance strategy and work plan each year. It also requires compliance professionals to look beyond the regulations, and find innovative and strategic ways to simplify the complex. This helps support our business partners in implementing regulations, executing corrective action plans, and demonstrating sustainable remediation when process breakdowns occur.   

Delivering on these commitments is one of the main reasons I continue to be challenged and energized every day. I hope you’re able to say the same! 

Jenny O’Brien, JD, MS, CHC serves on the advisory board for YouCompli. She is also president and principal at BlackBridge Advisors. She has been the chief compliance officer (CCO) at multiple companies, including UnitedHealthcare, as well as a state assistant attorney general and a partner at a law firm. She is a past president and board member of HCCA/SCCE, serves on the boards of Bon Secours Mercy Health System and St. Charles Health System, and the advisory board of Stellar Health. 

Qualified compliance professionals do the heavy lifting for you, simplifying regulatory change management    

Our in-house team works tirelessly to monitor US regulators, carefully read the regulations in their entirety, and translate the information into simple regulatory intelligence you can use. We deliver model procedures and expert tools that can be used to fulfill your business requirements. Everything is validated by a third-party law firm. Follow the button below to get a tour of our healthcare compliance software.   

Get the latest from healthcare compliance experts   

Never miss an article by Jenny O’Brien. Sign up for YouCompli’s weekly email if you haven’t already.    

The post The Value of “Operationalizing” Your Compliance Program  first appeared on YouCompli.