Is Compliance Mandated?
The Patient Protection and Affordable Care Act (ACA), Section 6401, mandated that providers put a compliance plan in place, but an enforcement date has not been issued for that requirement. That’s the short answer to whether healthcare compliance is mandated.
As further explanation, per the ACA, providers and suppliers must establish a compliance program as a condition of enrollment in Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). The compliance program must contain core elements that the U.S. Department of Health and Human Services (HHS) Secretary, in consultation with the HHS Inspector General, must establish. “The Secretary shall determine the timeline for the establishment of the core elements … and the date of the implementation,” the ACA states (as does the SSA).
However, the enforcement date for this ACA requirement hasn’t been set yet. Considering the ACA went into effect in 2010, the healthcare industry has had a lot of time to prepare and get compliance programs in place. If your organization still has work to do, resources like the 2014 CMS joint presentation with the OIG may assist with designing your compliance program.
We also saw above that the Medicare Advantage contract requirements chapter of the Medicare Managed Care Manual mandates that MA organizations show a demonstrated commitment to compliance. (The manual goes on to state that MA plans offered to employees or union members may have different rules.)
Remember that Medicare is not the only payer that wants you to have a compliance program. Many state Medicaid units and commercial payers also require a compliance program. Some states require healthcare providers to have a compliance program, too, so organizations need to know both their state and individual payer guidelines.
To be clear, even without an enforcement date for the ACA requirement or specific information from states or payers, healthcare organizations need to comply with the rules and regulations that apply to them. Following the law regarding submitting accurate healthcare claims is not optional.