Assessing Your Compliance Program for Effectiveness

November 20th, 2023

This article was written by Heather Brownson, Senior Consultant, Compliance Solutions Division of The Bonadio Group.

Maintaining an effective compliance program should be a key component within any organization’s overarching strategy. In this article, we will be reviewing the importance of maintaining an effective compliance program and ways in which you can conduct a valuable assessment of your organization’s compliance program.

Assessing Your Compliance Program – Why?

As a Healthcare Provider, you need to ensure you are meeting all applicable Federal and State Regulations. Medicaid and Medicare require programs to have an effective compliance program. As a result, compliance programs must be monitored and audited to evaluate compliance with those standards.

To comply with these requirements, an organization should confirm that their compliance program is operating as designed, expected, and required; particularly before submitting annual certification for programs.

Additionally, conducting an assessment is part of a determination of effectiveness. State and federal compliance obligations require that compliance programs are effective and that an organization is monitoring, testing, and evaluating their compliance program for effectiveness.

Having an effective compliance program is part of good management control functions. This can help an organization drive operational efficiencies and reduce costs.

Assessing Your Compliance Program – How?

Once you have solidified what you will be assessing, you will need to determine how you will be conducting the assessment. Below are some tips to keep in mind.

  1. Assess the structure of your compliance program. Are all the required elements in place?
  2. Assess if the compliance program is operating effectively. Can you demonstrate that the compliance program is effective?
  3. What are the findings of your compliance program?
  4. When a negative finding is identified, do you conduct a root cause analysis to determine why a negative finding is occurring?
  5. When you identify the root cause do you develop and implement a plan of correction?
  6. Do you go back and test the plan of correction to ensure it is correcting the root cause of the problem?
  7. Are plans of correction periodically revisited to confirm that they are still correcting the root cause?
  8. Have any other “related” negative findings been identified that need a root cause analysis?
  9. Do you do a regular risk assessment to determine what areas should be tested more frequently or in more depth?
  10. Be mindful that an assessment is not only about the compliance program, but also about performance under the program requirements such as Medicare and Medicaid.
  11. Have you developed a Compliance Work Plan that includes assessment of the compliance program, risk assessment, and analysis of program changes?
  12. Have you engaged all levels of the organization in the assessment process, through interviews, meetings, etc.?

Assessing Your Compliance Program – Who?

Now that you have ironed out the what and the how, it is time to determine the who. It is important to remember, compliance is not just one department. Everyone has a stake in the compliance program. While a compliance officer can spearhead the compliance program and ensure that the organization has appropriate tools in place, such as a Compliance Work Plan that addresses risk, it is the Executives, Management, various departments, and the governing body that help ensure the organization is in compliance.

The other “who” that plays a factor in the assessment process are external government oversight agencies that your organization reports to (Medicaid, Medicare, US Department of Health, etc.).

It is these factors that you will want to keep in mind when you are determining who to include in the assessment.

Assessing Your Compliance Program – When?

Below are some examples as to when you would want to assess your compliance program:

  • When compliance issues that have been identified and there is a need to conduct focused assessments
  • When regulatory requirements dictate
  • During or as part of root cause analysis
  • At reasonable intervals to assess plans of correction
  • When regulatory or program changes take place
  • When there is a change in Management staff

Assessing Your Compliance Program – How Often?

As the adage goes, timing is everything and that also applies to when you assess your compliance program. While you will want to constantly be reviewing the compliance program, you should at minimum be conducting the assessment annually or incrementally over the course of the year.

In Summary…

In summary, we have reviewed the importance of an effective compliance program and how an assessment ensures your compliance program is effective. Keep the following key points in mind when conducting your review to ensure your organization’s compliance program is effective.

  • Why?
    • Having an effective compliance program is required by law and regulation. It also helps drive operational efficiency and lowers operational costs. An effective and successful compliance program also allows sound sleep, as you know the organization is doing the right thing.
  • How?
    • Ensure you are routinely conducting root cause analysis’ and testing your plans of corrections frequently.
  • Who?
    • Remember, compliance is everyone’s responsibility and plays a key role in the assessment.
  • When?
    • You should be conducting an assessment at least annually, but it is best practice to be an ongoing process.
  • How Often?
    • Don’t just make it a large once-a-year project, conduct pieces of the assessment throughout the year.

In order to maintain an effective compliance program in accordance with regulations or guidance from the federal government, organizations must diligently familiarize themselves with the entirety of the expectations and standards. Organizations may also consider aligning with a trusted advisor who can provide further guidance and ensure their compliance program satisfies the necessary requirements. The Compliance Solutions team at Bonadio can assist with compliance program assessments.

If you need further guidance or have any questions on this topic, we are here to help. Please do not hesitate to reach out to discuss your specific situation.

Heather Brownson is a Senior Consultant with The Bonadio Group’s Compliance Solutions Division with more than 15 years of experience in not-for-profit settings. She has held positions of Director of Quality Assurance, Associate Director of Compliance, Compliance Specialist and Employment Coordinator for organizations regulated by local state and federal laws. She has conducted compliance trainings and assessed compliance programs for various organizations and is a great compliance program resource for clients.

This material has been prepared for general, informational purposes only and is not intended to provide, and should not be relied on for, tax, legal or accounting advice. Should you require any such advice, please contact us directly. The information contained herein does not create, and your review or use of the information does not constitute, an accountant-client relationship.

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