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Compliance > Seven Comp Elements

The Seven Elements For An Effective Compliance Program

An effective compliance program demonstrates a provider's commitment to discovering and eliminating fraudulent practices and to making sure that no such problems arise in the future. In the event the provider is prosecuted for fraudulent practices, an effective compliance program will reduce the level of sanctions, fines and penalties imposed against the provider for any violations which occur in spite of the existing policies. In fact, the federal sentencing guidelines for organizations specifically provide for a reduction in the penalty imposed if the violator had an effective compliance program to prevent and detect violations of law in place at the time of the violation.

The following are the seven elements for an effective compliance program, as outlined by the OIG, and the steps the Jefferson has taken to make the compliance program conform to these guidelines.

1. Policies and procedures: The organization must have established compliance policies and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of criminal conduct.

· Establishment of the TJU Code of Conduct 107.02
· Establishment of the TJU Conflict of Interest Policy 107.03

2. Compliance oversight: Specific individual(s) within high-level personnel of the organization must have been assigned overall responsibility to oversee compliance with such standards and procedures.

· The Corporate Compliance Staff

3. Due diligence: The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known, through the exercise of due diligence, had a propensity to engage in illegal activities.

· Limitation on Employment 107.16
· HR Monitoring Program to prevent the employment of sanctioned individuals

4. Employee training: The organization must have taken steps to communicate effectively its standards and procedures to all employees and other agents, e.g., by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required.

· Sanctions for Failure to Attend Mandatory Educational Programs 107.07
· Education and Training Requirement for All JUP Personnel Involved in the Coding Process 107.12

5. Auditing and monitoring compliance: The organization must have taken reasonable steps to achieve compliance with its standards, e.g., by utilizing monitoring and auditing systems reasonably designed to detect criminal conduct by its employees and other agents and by having in place and publicizing a reporting system whereby employees and other agents could report criminal conduct by others within the organization without fear of retribution.

· ComplyLine, 107.01
· Policy on Reporting and Retaliation, 107.06
· Responsing to Alleged Misconduct in Research 110.02

6. Discipline policies: The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense. Adequate discipline of individuals responsible for an offense is a necessary component of enforcement; however, the form of discipline that will be appropriate will be case-specific.

· Disciplinary Actions Related to Corporate Compliance Program 107.15
· Conflict of Interest Policy-Enforcement and Sanctions for Non-Compliance 107.18
· Sanctions for Failure to Attend Mandatory Educational Programs 107.07
· Compliance Provisions in the TJU and JUP Medical Staff By-Laws

7. Prevention: After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses - including any necessary modifications to its program to prevent and detect violations of law.

· Auditing and Monitoring Programs

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