Exploring healthcare compliance as a career
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This article was reviewed by Mark Jóhannsson, DHSc, MPH, Dean, College of Health Professions
At a glance
- Healthcare compliance is the practice of adhering to federal healthcare laws and regulations.
- Compliance laws are intended to help protect patients, safeguard sensitive information and help mitigate and prevent fraud, abuse and waste in the healthcare industry.
- Noncompliance poses serious risks to patients and can result in legal action.
- Enhance your understanding of healthcare compliance with a Bachelor of Science in Health Administration from University of Phoenix.
Global healthcare is a trillion-dollar industry that focuses on the safety and care of patients. In the U.S., compliance in healthcare is of the utmost importance due to the sheer size of the industry, the risks associated with it and its dynamic nature. These factors open up the possibility of fraud and abuse, and this is where healthcare compliance comes in.
Healthcare compliance is the practice of adhering to federal healthcare laws and regulations, which prohibit and prevent fraud, abuse and waste in the healthcare industry. It’s founded on ethical standards for patient treatment.
Learn what healthcare compliance is, what the laws are and how to ensure a healthcare facility complies.
Healthcare compliance laws
Many laws regulate the healthcare industry. While the following isn’t an exhaustive list of laws and regulations, these are some important ones:
- Health Insurance Portability and Accountability Act (HIPAA): Protects private patient information from being shared without a patient’s knowledge or consent.
- Health Information Technology for Economic and Clinical Health (HITECH) Act: HITECH expands the scope of HIPAA and provides healthcare facilities with certain standards for using IT to implement electronic health records (EHR).
- Emergency Medical Treatment & Labor Act (EMTALA): This law was enacted to ensure the public can access emergency treatment regardless of whether they can pay.
- Patient Safety and Quality Improvement Act (PSQIA): This law was enacted to encourage the reporting, discussion and resolution of patient safety issues. It also authorizes the Agency for Healthcare Research and Quality to provide a database of Patient Safety Organizations (PSOs).
- Anti-Kickback Statute: A statute that prohibits providers and organizations from receiving financial incentives for a patient referral when the federal government may be charged for those services.
- False Claims Act (FCA): Under the FCA, filing a false claim for federal program funds is illegal and punishable with fines from $11,803 to $23,607.
These laws are in place primarily to protect patients and ensure that all individuals have equitable access to healthcare in the U.S.
Who is responsible for healthcare compliance?
Everyone in a healthcare organization must adhere to the healthcare regulations established by the government. It’s the responsibility of every professional to make sure they are acting ethically and per all laws. Many healthcare organizations have a compliance officer, or a similar role, to help ensure the facility is compliant.
Having someone in a designated role can help make it easier for a facility to coordinate or communicate with government agencies or third-party organizations that maintain healthcare compliance standards.
Multiple government agencies and a not-for-profit organization are involved in maintaining compliance programs:
- Department of Health and Human Services (DHS): A federal agency focused on improving the health, safety and well-being of every American.
- Drug Enforcement Administration: A federal government agency tasked with combating drug trafficking and distribution in the U.S., including prescription drugs.
- The Joint Commission: A not-for-profit institution that introduced a standard for accreditation of healthcare organizations in the U.S.
- Office of the Inspector General: An office within the U.S. Department of Health and Human Services whose mission is to protect the integrity of DHS programs through audits and investigations.
- Food and Drug Administration (FDA): An entity that regulates the information that must be included and disclosed on prescription drugs. The FDA also approves or disapproves prescription drugs to be used in healthcare.
These entities can provide resources and guidance on any healthcare compliance issues you might encounter.
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The importance of compliance in healthcare
A compliance program in healthcare is important for many reasons. For starters, the stakes are high. Healthcare compliance is meant to help prevent fraud or abuse of patients.
Healthcare compliance and regulations also protect patient privacy and safety and encourage healthcare professionals to provide high-quality care to all patients. It also dictates how to bill patients properly. Not only do compliance program regulations protect people, but they also protect valuable information.
Complying with health information technology laws and regulations can help protect against any potential data breaches or cybersecurity threats.
Adhering to the federally instated laws and regulations allows a healthcare organization to protect its patients and become a credible organization.
The consequences of noncompliance
In healthcare, the consequences of noncompliance are serious and may result in legal actions. The consequences are so major because of the risk to patient safety and privacy that noncompliance poses.
If a healthcare organization is noncompliant, it will face fines and legal charges, not to mention a damaged reputation. Patients seek a high quality of care; if they are in the market for a new healthcare provider, they are more likely to choose one who hasn’t been involved in a lawsuit or complaint.
How to ensure compliance in healthcare settings
To adhere to healthcare compliance requirements, you should have a compliance plan in place — a plan that includes clear directives and policies and a designated compliance person, as well as training and audits. Anyone pursuing a job or completing an education in healthcare should have some exposure to relevant standards, regulations and compliance guidelines, although the exact role (for instance, clinical versus clerical) may dictate additional or more specialized training in compliance.
Develop clear policies
Healthcare organizations need clear policies for every component of compliance and a fully developed organizational compliance plan. Create policies that adhere to each law and regulation. This will promote consistency in production and high-quality service among your providers and healthcare staff.
Make sure all policies and requirements are incorporated in onboarding and accessible by every employee.
Designate a compliance officer
A compliance officer is someone who helps standardize and enforce all healthcare regulation requirements and laws at an organization. Compliance officers should also know how to identify risks and find remedies. Additionally, they ensure that all healthcare systems are sufficient and updated to protect patient records and private information.
Compliance officers should be fully educated in healthcare compliance and understand how each law impacts day-to-day tasks. This education generally involves at minimum a bachelor’s degree in healthcare administration, though some positions may benefit from the deeper education involved in completing a master's degree in healthcare administration.
Train employees
All healthcare employees go through compliance training when they are onboarded and then regularly thereafter. While your compliance officer is responsible for standardizing compliance policies and identifying risks for the overall organization, all healthcare employees should be trained in compliance.
Employees who have undergone training are better able to understand compliance risks. When employees have a clear understanding of the regulations, they can work with compliance officers or other organizational leaders to ensure the safety of patients and sensitive information.
Conduct compliance audits
Your compliance officer conducts regular healthcare compliance audits. Compliance audits can help you identify potential hazards or risks before they become a bigger problem.
An audit evaluates the strengths and weaknesses of your compliance policies and procedures. The evaluation helps identify areas for improvement and where noncompliance might pose risk. A compliance officer then makes changes accordingly.
Deal with noncompliance immediately
An organization must have policies in place to mitigate noncompliance issues. A compliance officer makes sure the policies tell employees how to report issues so that when one comes up, it’s addressed right away.
Issues of noncompliance can be an opportunity to educate employees. A compliance officer can show them that proactively responding to noncompliance will help the organization prevent future incidents and improve overall compliance.
