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Health Care Blog

Setting Up Your Compliance Internal Reporting Mechanism

Authored by John H. Fisher, II
Posted on March 3, 2017
Filed under Health Care

One of the primary elements in a Compliance Program is the creation of a system that permits employees and others to provide information regarding potential compliance issues without fear of retaliation.  In larger organizations, multiple pathways permitting employees to make anonymous complaints should be maintained.  Oftentimes providers use 24 hour compliance “hotlines,” compliance “lockboxes,” and other methods to facilitate compliance tips.

Whatever system is used as part of your compliance reporting system, it is crucial employees understand they are encouraged to provide information and there is a clear prohibition against others in the organization retaliating against them for providing information.  It should also be made clear to employees that the desire of the employee to remain anonymous will be honored.

Establish Compliance Reporting Process

Absent a system to encourage reporting, it is hard to imagine a compliance program being found to be effective.  Effectiveness is the standard all compliance programs must meet in order to provide any risk mitigation.  All government standards for compliance require the program be “effective.”  A well designed and properly operated reporting system will help the business obtain valuable information, hopefully early on, before the issue becomes a big problem.  Additionally, the openness of the program will send a strong signal to the outside world, such as government regulators, that the organization takes compliance seriously.

If information is obtained through the compliance reporting system it must be taken seriously.  Certainly not every piece of information will be reflective of a serious compliance problem and an employee could potentially have other motives for making a compliant.  Regardless, it is crucial the information be acted upon and the action be documented.  If the compliance officer concludes there were alternative motivations for the complaint, that fact should be substantiated and documented.  If an objective investigation indicates there could be a compliance issue, the matter needs to be pursued through an appropriate outcome. Depending on the circumstances and the result of a thorough investigation, the outcome could range anywhere from additional training through a self disclosure to the government.