Medical Compliance Programs

What is the best way to avoid healthcare violations? Design a Medical Compliance Program. These are simply a set of effective internal controls to ensure guidelines, regulations and laws affecting the organization are followed. They are meant to encourage a culture that fosters prevention, detection, and a resolution of conduct that is outside the established company policies. The Federal Sentencing Guidelines encourage compliance programs in order to reduce criminal fines and penalties. Medical Compliance Programs have seven basic elements:

  1. Develop and distribute policies that define standards and procedures to be followed by the organization’s agents and employees, such as standard of conduct and commitment to compliance.
  2. Designate or develop a high-level employee who has ultimate responsibility to operate and monitor the program and report directly to the CEO.
  3. Use reasonable care to identify sanctioned providers and remove those individuals from any activity that would violate any law or regulation.
  4. Require regular training programs for all employees and/or contractors.
  5. Use monitoring and proactive auditing systems to detect fraud and unusual trends to ensure compliance.
  6. Establish and publicize a reporting system where employees can report violations without fear of retribution.
  7. Develop a system to respond to allegations and investigate as needed.


The Office of the Inspector General has devised model compliance guidelines for hospitals, clinical laboratories, durable medical equipment companies, and home health companies. Look for the contents of the model plans at the Department of Health and Human Services website.

Hospital Receivables Service, Inc. offers full medical billing solutions for all medical practices including MD offices, ancillaries, and hospitals. We provide billing, insurance collection, early out collection, and bad debt collection. All collectors are properly trained, compliance is enforced, and there is a full time fraud examiner on staff. Contact us today at 800-940-2455 to see how we can maximize the return on your medical billing and collections.

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