- Corporate businesses and health care organizations alike may besubject to criminal and civil actions
under a variety of federal and state laws, including the FalseClaims Act, the Wire and Mail Fraud
Act, securities and employment laws, and a number of others. Intoday’s business market, many
organizations have adopted corporate compliance programs to educateeveryone from top executives
to line-staff employees on the laws and regulations that affecttheir operations. A corporate compliance
program can prevent both intentional and accidental wrongdoing andcan be viewed positively by
investigators and the courts, often reducing civil or criminalpenalties. The mere existence of a
compliance program, however, does not excuse any corporation ofwrongdoing. In fact, a poorly planned
and executed compliance program can be viewed worse than having nocompliance program at all.
Health care providers need to address many of the same complianceconcerns as their corporate
counterparts. In addition to the laws and regulations already inexistence, health care providers face
continuing enforcement initiatives from the Centers for Medicare& Medicaid Services (CMS), the Office
of Inspector General (OIG), the United States Department of Justice(DOJ), and various national and
state accreditation bodies. In addition to conducting federal andstate payer oversight, private payers
are also engaged in reviewing and auditing health care services forquality, medical necessity, and health
care financial waste. Health care organizations today must have acomprehensive corporate compliance
program that embodies accountability, responsibility,investigation, and education.
A health care provider’s compliance program will consist of variouspolicies and standards and
will vary depending on the specific entity. Generally, corporatecompliance programs include policies
and procedures designed to define and identify laws andregulations, correct identified problems, and
put controls in place to prevent future problems.
In a Worddocument; please define the following:
CERT
RAC audit
Medicalnecessity
NCCI edit
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