How Compliance Can Leverage the OIG’s 7 Elements and HHS Roadmap
With the end of the COVID-19 Public Health Emergency (PHE) coming in May, many healthcare compliance leaders are in the process of slowly returning their organizations to normal. Let’s revisit the seven elements and how they can help you shape the patient experience. Reviewing operations in the context of the seven elements can help you ensure that your organization has a smooth transition back to pre-pandemic operations.
Relying on the Seven Elements and the HHS Roadmap as Resources
Months ahead of the COVID-19 PHE expiration date, the U.S. Department of Health & Human Services posted a fact sheet and transition roadmap. It addressed which patient care and services will – and won’t – be affected, and it remains a helpful guide now.
The seven elements in the OIG’s effective compliance program are also useful as we consider how to best deliver quality patient care post-PHE. Each element is an opportunity for compliance officers to position their organization to provide the best patient care.
1. Implementing Written Policies, Procedures and Standards of Conduct
From a patient perspective, complying with this element means ensuring that staff are educated and aware of written policies and procedures. For example, the following services will not be affected post-PHE:
- Medicare and Medicaid telehealth visit flexibility
- Access to COVID-19 vaccines
- COVID-19 treatments such as Paxlovid and Lagevrio
As we restore standard operations, prioritize reviewing policies and procedures for staff to ensure they are current. It’s also critical to create standards of conduct for staff and hold them accountable to those standards. Be sure to implement ongoing staff education programs.
2. Designating a Compliance Officer and Compliance Committee
For patients, this element involves ensuring that they have a point of contact for filing a complaint or grievance. Be sure they can do so anonymously, if they choose. Post-PHE, we can anticipate that complaints and grievances may focus on improper:
- Billing for telehealth visits
- Copays for medications
- Scheduling of in-person appointments, when the patient requested a telehealth appointment
Compliance officers may want to emphasize reviewing the processes and procedures around billing and coding. Also review your practices to be sure staff receive updated education on charging and collecting proper copays.
3. Conducting Effective Training and Education
Compliance leaders fulfill the third element by helping to ensure that patients understand what services are affected when the PHE has expired. Compliance officers are instrumental to making sure patients know details such as:
- That access to free over the counter COVID-19 tests has ended, unless there is a state waiver in place
- That reporting COVID-19 test results is no longer mandatory for all healthcare providers
- That they have the option to continue receiving care via telehealth, when clinically appropriate
This element calls on you to ensure that training materials are easy to understand and are shared in a variety of formats. Some effective formats include online on the patient portal and verbally at registration.
4. Developing Effective Lines of Communication
This element involves making sure patients are comfortable asking about the organization’s policies and procedures related to the PHE and more.
Compliance leaders can implement this element in several ways, including by:
- Providing patients and staff with easy-to-read materials regarding changes post-PHE
- Posting the grievance policy in multiple areas and in the top languages spoken in the community
- Ensuring that employees know how to contact Compliance and how to find the compliance hotline number
- Checking in with compliance champions, or liaisons, to see what’s happening in departments and clinics throughout the organization and timely addressing concerns
5. Conducting Internal Monitoring and Auditing
The fifth element extends to patient privacy after the PHE. Among the compliance activities to prioritize post-PHE, the compliance officer should help make sure staff are educated on how to:
- Protect patient privacy and confidentiality during registration
- Protect patient health information so it is not visible to other patients or visitors
- Follow the compliance workplan to provide compliant, consistent, and confidential patient care
- Understand benchmark audit data
6. Enforcing Standards with Accountability
The goal of the sixth element is to ensure operational responsibility. Its correlation to patient care primarily focuses on making sure patient services are delivered in a compliant manner.
Using a post-PHE lens means supporting patients in understanding what service and billing changes will occur, such as collection of copays for telehealth visits. During the PHE, providers were permitted to reduce or waive cost-sharing copayments or deductibles for telehealth services provided to Medicare beneficiaries. After the PHE expires May 11, full Medicare copayments for telehealth services must be charged and collected. Again, this element requires compliance leaders to provide staff education and training and then hold staff accountable to the current regulations and policies. It also involves reporting any compliance infractions to the employee’s supervisor, compliance committee, and the board, if needed.
7. Responding Promptly to Identified Offenses and Undertaking Corrective Action
This is where compliance leaders can lead by example when it comes to being responsive to patients’ concerns. Compliance officers can help ensure that staff take prompt action to improve the patient experience by:
- Confirming whether the patient is requesting a telehealth or in person visit
- Providing timely responses to written complaints or grievances
- Promptly correcting billing problems and processing refunds quickly
- Correcting copayment mistakes during the visit
Compliance leaders are responsible for requesting timely corrective action plans, as needed, and reporting disciplinary actions to the board and required regulatory body, if needed.
Patients may see the end of the PHE as a welcome sign of everyday life returning to normal. For compliance officers, post-PHE preparations have been as extensive as the pivots required when the pandemic first hit. Relying on the OIG’s seven elements and the HHS roadmap can help compliance professionals best support their organization in the transition to pre-pandemic operations.
Help Working with Operations
YouCompli subscribers can manage tasks and activities related to the end of the public health emergency with our workflow tool. Compliance can send notifications of regulatory changes to operations. Our solution enables the right people in the right departments to update policies and procedures as well as monitor the progress of the required changes. The YouCompli dashboard, embedded in our verify feature, enables Compliance to monitor the process and verify that the work gets done by the deadline. Find out how.
Denise Atwood, RN, JD, CPHRM
District Medical Group (DMG), Inc., Chief Risk Officer and Denise Atwood, PLLC
Disclaimer: The opinions expressed in this article or blog are the author’s and do not represent the opinions of DMG.
Denise Atwood, RN, JD, CPHRM has over 30 years of healthcare experience in compliance, risk management, quality, and clinical areas. She is also a published author and educator on risk, compliance, medical-legal and ethics issues. She is currently the Chief Risk Officer and Associate General Counsel at a nonprofit, multispecialty provider group in Phoenix, Arizona and Vice President of the company’s self-insurance captive.