Recent OIG General Compliance Guidance…Key Resource for HIM Leaders

: a blue checkmark on a blocks of wood representing OIG compliance points for healthcare HIM leaders

The Office of Inspector General (OIG) has updated their healthcare Compliance Guidance with a “General Compliance Program Guidance” document. This new guidance reinforces the seven key elements of a compliance program and serves as a vital resource for all healthcare settings.

You may or may not have seen or read about the Office of Inspector General (OIG) release November 5th, 2023 of the updated General Compliance Guidance for the healthcare industry. The new guidance is being referred to as “General Compliance Program Guidance”, or “GCPG”. This guidance document can be accessed at the following OIG site: https://oig.hhs.gov/compliance/general-compliance-program-guidance/

Some of you may remember when the OIG published this guidance originally back in 1998 due to the increase attention to fraud and abuse. Per the current OIG program guidance, “The GCPG provides information about relevant Federal laws, compliance program infrastructure, OIG resources, and other items useful for understanding health care compliance. The GCPG is voluntary guidance that discusses general compliance risks and compliance programs.”

The sections of the OIG “General Compliance Program Guidance” includes the following:

  • Introduction
  • Health Care Fraud Enforcement and Other Standards: Overview of Certain Federal Laws
  • Compliance Program Infrastructure: The Seven Elements
  • Compliance Program Adaptations for Small and Large Entities
  • Other Compliance Considerations
  • OIG Resources and Processes
  • Conclusion

Within each section are many excellent observations and recommendations for healthcare. The seven key elements of a compliance program are similar to prior OIG guidance and are foundational for any healthcare organization, system and/or setting. The seven GCPG are:

  1. Written Policies and Procedures
  2. Compliance Leadership and Oversight
  3. Training and Education
  4. Effective Lines of Communication with the Compliance Officer and Disclosure Program
  5. Enforcing Standards; Consequences and Incentives
  6. Risk Assessment, Auditing and Monitoring
  7. Responding to Detected Offenses and Developing Corrective Action Initiatives

The OIG has published several CPGs and they include the following:

  1. hospitals;
  2. home health agencies;
  3. clinical laboratories;
  4. third-party medical billing companies;
  5. the durable medical equipment, prosthetics, orthotics, and supply industry;
  6. hospices;
  7. Medicare Advantage (formerly known as Medicare+Choice) organizations;
  8. nursing facilities;
  9. physicians;
  10. ambulance suppliers; and
  11. pharmaceutical manufacturers.

As we always say, “Compliance Starts at the Top” and this is still a true statement. This means that HIM leaders (Directors, Managers and Supervisors) need to be well-informed and aware of this program and the elements within. We ALL need to take responsibility for addressing compliance and preventing fraud, waste, and abuse. HIM Leaders should take the seven elements and look at how and when this applies to their departmental operations and processes. Be proactive rather than reactive is a best practice to take when it comes to compliance.

So, what are you waiting for? Please review this OIG document and share it with your peers, colleagues, and organizational leadership. Set aside time to discuss compliance with your staff and encourage them to come forward with any related concerns of fraud, waste and/or abuse.

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This program has been approved for continuing education unit(s) (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting of Approved CEUs from AHIMA does not constitute endorsement of the program content or its program provider.