On the Road to Compliance: How a Committee Could Lead You to Your Final Destination

By | Published On: November 3, 2016

If, as we near the end of 2016, your health center has a lot of unaccomplished items on its compliance work plan or “to do” list, it may be time to develop a staff-level Compliance Committee.

In most health centers it is not feasible for the compliance officer to be the only individual responsible for implementing compliance program functions or for ensuring compliance by all individuals affiliated with the organization.  A staff Compliance Committee assists the compliance officer in overseeing the organization’s compliance program.  There are two main purposes for the committee: to collect and process information from throughout the organization and to operationalize the compliance program within the organization.

No compliance officer can be expected to be an expert in all areas of the health center’s operations.  The Compliance Committee should be able to contribute to the compliance officer’s knowledge and understanding of legal and regulatory requirements related to the various operations of the organization.  For instance, a billing manager would be able to contribute substantively to a compliance officer’s understanding of technical billing requirements.

Similarly, a compliance officer cannot be in all places at all times, monitoring all of the health center’s staff to ensure compliance.  An effective Compliance Program will require individuals to report compliance issues and concerns either to their supervisors or to the compliance officer or other member of upper management.  It is these supervisors and managers who, as members of the staff Compliance Committee, can assist the compliance officer in gathering information on staff activities and concerns within the various departments of the organization.

For example, the director of behavioral health is more likely to be aware of compliance issues among the behavioral health clinicians than a compliance officer alone would be.  Similarly, a finance director is likely have access to, and knowledge of, the health center’s audit reports.

By centralizing staff Compliance Committee members’ substantive knowledge and their familiarity with the organization’s activities into the Compliance Program, a compliance officer can gain valuable information that can help with the development of a compliance work plan to prioritize compliance program efforts.   Moreover, having the staff Compliance Committee assist in developing a compliance work plan can often help to achieve staff buy-in more easily than if compliance activities are simply mandated by the compliance officer.

In conclusion, establishing a staff Compliance Committee can be an effective method for increasing the compliance officer’s knowledge base,   assisting in developing a work plan and taking full advantage of organizational strengths.

The Corporate Compliance Toolkit for Health Centers has numerous Compliance Program resources to assist in developing a staff Compliance Committee, including:

For information on the documents included in the Corporate Compliance Toolkit for Health Centers, please contact HealthCenterCompliance@ftlf.com.

Lastly, check out our upcoming Corporate Compliance training in January in Seattle, WA.

Ms. Pledgie is a member of the New York and Massachusetts Bars and is not licensed in Washington, DC. Her practice is limited to federal health care matters.