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What is healthcare compliance?

Next to hands-on patient care, no part of healthcare carries as much importance as protecting a patient’s personal information from a breach of privacy, charging honestly for the care provided, and auditing the compliance of a practice or facility.

All medical organizations face healthcare compliance worries. Healthcare compliance is a general term describing the observance of conventions, guidelines, and state and federal laws. Practices, clinics, and facilities normally have a staff members dedicated to fulfilling regulations that protect patients and staff, assure privacy of personal information, and that medical information is presented using standardized means.

Since 2003, when the Healthcare Information Portability and Accountability Act of 1996 (HIPAA) was implemented, a new role of Compliance Officer has evolved. Compliance Officers assure compliance with all facets of HIPAA rules, developing and maintaining compliance plans, training staff and providers, and correcting any irregularities.

HIPAA requires providers and facilities to maintain compliance plans requiring monitoring and training. Often, there is a designated compliance officer who must develop, track, and report on these plans, which may include regulations from the Occupational Safety and Health Administration (OSHA), the Health Information Technology for Economic and Clinical Health Act (HITECH), the Office of Inspector General (OIG), and others.

Follow the links to answers to your questions about HIPAA.

Become a Healthcare Compliance Officer

AAPC offers the Certified Professional Compliance Officer (CPCO™) credential to help address the ever-growing compliance requirements of government laws, regulations, rules, and guidelines.

This healthcare compliance certification demonstrates that you understand the key requirements needed to effectively develop, implement, and monitor a health care compliance program for your practice based on governmental regulatory guidelines. This includes being knowledgeable in compliance reviews, audits, risk assessments, and staff education and training. With the CPCO™, you’ll obtain expertise in areas such as:

  • Office of Inspector General (OIG) compliance guidance
  • Health care fraud and abuse laws (False Claims Act, Stark Laws, and Anti-kickback Statute, etc.) including associated penalties
  • Provider Enrollment and Chain Ownership System (PECOS) verification
  • How the Affordable Care Act will affect medical practices
  • Health Insurance Portability and Accountability Act (HIPAA), EMTALA, and Clinical Laboratory Improvement Amendments (CLIAs)
  • Handling investigations, including self-disclosure protocols
  • Requirements under Corporate Integrity Agreements (CIAs) and Certificate of Compliance Agreements (CCAs)
  • Government investigative audit programs (for example, recovery audit contractors (RACs), Zone Program integrity contractors (ZPICs), State Medicaid Fraud Control Units (MFCUs))
  • Risk areas such as receiving gifts or gratuities, conflicts of interest, use of Advance Beneficiary Notices (ABNs), teaching physicians guidelines, and incident-to services

If you are a certified healthcare compliance officer and want to take your expertise, credentials, and career to the next level, consider becoming a CPCO™ through AAPC. You already have the background and know how to follow proper coding, billing, and claim requirements, so you have a jumpstart on understanding government rules and regulations in health care. Find out more here.

What It Means to Patients

Compliance means each patient can rest assured their information is not only protected but the right information is accessible to the right audience. While the obvious focus is making sure providers have the information they need, support workers such as social workers need access to the right information. And the right information needs to go to payers and regulators.

Compliance and the audits needed to confirm the practice are necessary to the proper care of each patient.

What It Means to the Healthcare Industry

Compliance adds levels of complexity to healthcare. Providers and facilities were forced to appoint or hire Compliance Officers to assure procedures are updated, training is performed, rooms are modified, computers and other electronic means are secured, and audits and reporting are carried out.

While this has presented new challenges to providers and facilities, it has also helped standardize how patients and everything associated with them are treated. As a result, quality management becomes easier as the data is prepared for tracking and improvement.

What It Means to AAPC Members

AAPC members are finding that new roles are growing from the role of a coder all the time, and Compliance Officer is one of them. Coders are often chosen to serve as Compliance Managers because of their expertise of HIPAA.

This growth can be enhanced with Certified Professional Compliance Officer (CPCO) certification.


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