What is a Healthcare Compliance Officer?

As government agencies and national regulatory organizations pass more regulations and the need for healthcare services grows, healthcare compliance officers (HCOs) are more important than ever. Healthcare entities must comply with an increasingly complex and changing set of laws and regulations. The violation of these regulations can compromise patient safety, breach patient privacy, and incur strict legal and financial penalties. Accordingly, maintaining compliance has become a key focus for healthcare facilities.

Facilities increasingly rely on healthcare compliance officers (HCOs) to bridge the gap between government regulation and daily operations. HCOs create systems within the practice to ensure that compliance with healthcare regulations is a smoothly administered routine. HCOs are expected to not only understand healthcare legal issues, but also to work with the hospital or healthcare facility to create practices and procedures that protect the entity, the practitioners, and the patients.

HCO Qualifications

Qualifications for healthcare compliance officers vary but have become increasingly strict as healthcare compliance regulations have grown in complexity. In addition to meeting educational requirements, healthcare compliance officers are expected to earn and maintain industry certifications. These can include Certified in Healthcare Compliance (CHC), Certified in Healthcare Privacy Compliance (CHPC), Certified in Healthcare Research Compliance (CHRC), and Certified in Healthcare Compliance Fellow (CHC-F).

An extensive knowledge of healthcare law is necessary, but HCOs also need to understand the ins and outs of medical office practices. A healthcare compliance officer needs to be familiar with:

• Coding
• Billing
• Reimbursement
• Healthcare administration
• Clinical activities
• Risk management
• Investigative activities and protocols
• Healthcare agencies and regulatory standards

This background knowledge provides a solid foundation for the HCO to administer the responsibilities of the position. The daily reality of working with patients, practitioners, and medical staff can be complicated when administering new compliance standards, so it’s vital for healthcare compliance officers to possess excellent leadership and communication skills.

Nine Responsibilities of Healthcare Compliance Officers

HCOs are responsible for developing a corporate compliance program and administering its implementation. Depending on factors such as type of practice and number of employees, this can consist of some or all of the following:

1. Creating a corporate compliance plan
2. Identifying potential risks
3. Ensuring proper creation, maintenance, distribution, and storage of documentation
4. Training employees on compliance issues
5. Handling complaints
6. Holding employees accountable
7. Safeguarding whistleblowers
8. Finding mutually beneficial solutions
9. Creating a culture of compliance

What Laws Govern Healthcare Compliance?

To help organizations maintain compliance with healthcare laws, a HCO must have expert understanding of the following laws and agencies:

• The Drug Enforcement Administration and the Food and Drug Administration govern the manufacture and distribution of medication and other controlled substances.
• The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act safeguard patient privacy by restricting the sharing of healthcare information and requiring healthcare organizations to keep patient records safe. 
• The Social Security Act establishes rules for reimbursement from Medicare, Medicaid, and CHIP.
• The False Claims Act prevents fraud and abuse by making it illegal to file false medical claims.
• The Patient Protection and Affordable Care Act establishes rules around insurance premiums, practices, and access to health insurance and Medicaid.
• The Department of Health and Human Services and the Office of the Inspector General maintain lists of healthcare providers who have had actions taken against their licenses for fraud or abuse.

HCO Best Practices Ensure Patient Safety

Healthcare compliance officers are responsible to safeguard patient privacy and safety. With the increasing use of telemedicine and resultant sharing of information via personal devices, it’s more important than ever to maintain security and privacy around patient information.

Whether it’s maintaining confidentiality between doctors and patients or familiarizing organizations with privacy laws such as HIPAA, a HCO helps facilities understand that patient privacy and security should be one of the highest priorities in healthcare compliance.

An HCO should also conduct regular audits to help ensure state and federal standards continue to be met. This is especially important to help healthcare facilities stay current as laws and regulations change. HCOs use their knowledge, preparation, and leadership skills to implement change within the organizations where they work. A well-organized healthcare compliance officer can help the facility not only maintain compliance and mitigate fines and penalties, but also increase communication, trust, and most importantly patient safety.

Learn more about how Verisys can assist your HCOs in meeting all government and regulatory standards.

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