Healthcare is one of the most regulated and complex industries in the United States. Agencies that provide ABA therapy as a medical service must take care to remain in compliance with shifting healthcare regulations. To this aim, ABA agency leaders must develop the systems necessary to ensure that staff understand and adhere to local, state, federal, and payor regulations, as the consequences of non-compliance can be severe.
Even the most well-intentioned ABA providers can run into trouble without a thorough compliance program. Compliance with government and payer policies, laws, and regulations reduces the risk of significant fines, disbarment from participation in certain programs, and even jail time. Health Care Fraud is a criminal offense punishable by up to ten years in prison and $250,000 in fines per incident.
In addition to general healthcare regulations, ABA providers face payer requirements and conditions set forth by our field’s certifying Board. ABA agencies may also develop unique internal policy requirements for clinical staff.
To navigate this complex environment, ABA leaders can turn to the U.S. Office of Inspector General (OIG) for compliance guidance and resources. Below are the seven elements needed for an effective compliance program.
The 7 Elements of an Effective Compliance Program
- Designate a Compliance Officer
- Document Policies and Procedures
- Train and Educate Staff
- Develop Effective Lines of Communication
- Develop Internal Monitoring and Audit Processes
- Enforce Standards
- Respond Promptly to Offenses with Corrective Action
As behavior analysts, we can think of the seven elements as proactive and reactive strategies that we can use to reduce the likelihood that our organizations engage in non-compliant behavior. While all of these elements are essential to an effective compliance program, when creating our own compliance program at Kyo, we found that elements 2 and 5 required some additional thought.
Designate a Compliance Officer
BCBAs make great Compliance Officers! They are already well-versed in monitoring data and implementing interventions, as needed. Depending on the size of your organization, the role of the Compliance Officer may be part-time or full-time. More time may be needed from your Compliance Officer in the early stages of developing your compliance program than is needed once you are in the maintenance phase. If your Compliance Officer is new to the world of healthcare compliance, consider what training they may need in order to be prepared to undertake their new role. Organizations such as HCCA (Health Care Compliance Association) offer comprehensive training programs, both online and in person, that can be invaluable in preparing your new Compliance Officer for their role.
Document Policies and Procedures
Once you’ve identified who will oversee your agency’s compliance program, it is time to start documenting all relevant policies and procedures. You will need to identify what needs to be documented, who the audience is for each policy or procedure, and where this policy will live (a policy that is only accessible to the policy writer does not do much good!).
Consider: What are the federal, state, payer, and organization-level requirements that I expect my employees to comply with? You will need to ensure that your organization has policies and procedures in place to address each of these requirements. For example, if you work with Medicaid patients, you are likely required to train your staff annually in Fraud, Waste, and Abuse detection. Do any of your payers have specific credential or educational requirements of staff? If so, what processes will you set up that will ensure only qualified clinicians are placed with those patients?
If the rules aren’t clear, ask questions and get the answers in writing. Not being aware of a requirement doesn’t absolve you from being expected to follow it.
Train and Educate Staff
It’s your responsibility to explain compliance requirements to your employees and make sure you’ve trained them in ways that enable them to comply with requirements. Depending on the nature of the requirement, you may need to provide training upon hire, annually, or perhaps even more frequently. In today’s virtual world, pre-recorded training videos are relied upon heavily and can be useful. However, live trainings that allow for Q&A may lead to a greater understanding of the policies or processes being disseminated.
Maintain detailed training records for every employee; you never know when you will be asked to produce proof that someone has completed a required training.
Develop Effective Lines of Communication
It is crucial that staff know where to go to get their questions answered, as well as whom to approach with compliance related concerns. Employees should understand that they face no retaliation for escalating a concern about compliance within your organization. At Kyo, we have found it helpful to set up a third-party hotline that allows employees to anonymously report any compliance concerns.
Conduct Internal Monitoring
In addition to creating policy documents and training your staff, regular internal monitoring is essential to identify instances of non-compliance and to determine when and for whom re-training is required. Consider a BCBA who works with four different payers, eight different behavior therapists, and 15 clients. They are likely to be responsible for overseeing 75 or more billable events per week, which have the capacity for thousands of potential rule violations!
Given the number of policies your agency has established, it is probably not realistic to expect that you will be able to set up robust monitoring systems for every single policy and procedure. You will need to decide which ones to prioritize for monitoring and balance that with the amount of effort and cost involved. Determining which policies have the highest risk to your company when it comes to non-compliance may help you to decide where to start.
At Kyo, we have leveraged technology to set up automated monitoring systems wherever possible. Things like code usage, supervision ratios, and upcoming certification expirations can all be monitored automatically, allowing whomever is doing the monitoring to quickly identify areas of concern, without having to manually dig through hundreds of billing entries.
While we have been able to create many automatic monitoring systems, we have found that there are some clinical elements that still require manual monitoring, including treatment plan content and clinical note content. An automated system cannot replace an experienced BCBA reviewing the clinical quality of these documents and ensuring that required components are included. However, depending on the size of your organization, it likely may not be realistic to have 100% of clinical documentation monitored. Focusing your time and attention on the documentation produced by new clinicians and clinicians who have previously been found to be deficient allows you to hone in on areas of high potential risk. Add to that a monthly review of a percentage of randomly selected clinical documents, and you will create an effective clinical note monitoring system.
Hopefully, setting up robust documentation and training programs will lead to an extremely compliant organization! It’s important to make employees aware of the potential repercussions of non-compliance and to apply compliance standards uniformly across your organization.
Respond Promptly to Offenses with Corrective Actions
Remember those effective lines of communication that were developed in element 4? When employees report concerns, it’s critical to take timely and appropriate follow-up action. Be prepared to take quick action when monitoring or auditing programs uncover potential healthcare compliance issues.
While the idea of setting up a robust compliance program for your ABA agency may feel overwhelming, it is well worth it in the long run. Healthcare compliance is such a serious matter that even accidental oversights can be financially devastating for a company. By dedicating some time and resources towards designing a compliance program that meets the 7 elements outlined above, your agency will gain a level of protection that will be beneficial for years to come.
To hear more about Kyo’s healthcare compliance program from its creators watch the full webinar on Youtube.
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You can also find more articles on a variety of ABA strategies here.