Compliance Reporting
What is compliance?
Compliance is an organization’s adherence to laws,
regulations, and policies applicable to its operations.
Violations may result in punitive action, including
the imposition of fines and/or criminal charges.
Clinicians have a responsibility to adhere not only to
their profession’s clinical and ethical standards, but
all applicable laws, regulations and policies.
What are corporate compliance programs?
A compliance program integrates health care federal and
state regulations, laws and professional standards and
company standards into a common framework and
provides a means for confidentially reporting concerns.
An effective corporate compliance program helps ensure
that clinicians and managers are conducting clinical
activities and business operations ethically, legally, and
with a high level of integrity. A successful compliance
program also helps develop a culture of accountability
and shared responsibility within an organization, facility,
or company. A compliance program may be developed
and carried out by the internal staff of the organization or
may be contracted to an external entity. In both instances,
the rules governing confidentiality of reporting and
protections are the same.
Compliance officers function as an independent and
objective body that is responsible for developing and
implementing the compliance program as well as
reviewing and evaluating compliance issues/concerns
within the organization. Specifically, compliance officers
carry out the following responsibilities:
• Serve as the primary point of contact for all
compliance concerns
• Direct compliance issues to appropriate resources for
investigation and resolution
• Represent an internal resource with whom concerned
parties may communicate
• Facilitate requests from external entities on behalf of
the organization in the case of denials, medical review,
and investigations related to fraud, waste, and abuse
• Have a duty to report violations to duly authorized
enforcement agencies as appropriate and/or required by
law
• Are legally bound to maintain confidentiality of those
reporting violations and to ensure those who report
violations not subject to retribution. In instances where
confidentiality has been breached or a retaliatory
measure has occurred as a result of information shared
with the compliance officer, the situation can be
reported to the Office of the Inspector General (OIG).
See the contact information at the end of this
document.
Confidentiality Versus Anonymity
Clinicians are often confused by the terms confidential
and anonymous—particularly in regard to which
reporting method provides the most protection when
reporting waste, fraud, and abuse. Confidential reporting
identifies the reporter to the compliance officer and
transfers legal protection to the reporter. When reporting
compliance issues to a designated compliance officer,
confidentiality provides the best protection and is
accomplished by making the report official rather than
attempting to report without disclosing your identity.
Anonymity is the concept of cloaking the identification
of the reporter. Anonymity can be hard to maintain and
does not allow protections under the applicable federal
and state whistleblower laws if the identity of the
reporter is discovered.
Recommended Steps for Reporting
• Immediately stop engaging in any activity that you
believe to be a compliance violation.
• Discuss concerns and questions with your immediate
supervisor.
Although concerns are best addressed directly,
remember that only compliance officers are legally
bound to ensure confidentiality and whistleblower
protections.
• Contact your facility and/or corporate compliance
officer or hotline.
Go to the compliance officer for
your direct employer if you are not employed by the
facility where you work. If they do not respond
satisfactorily, you can go to your facility compliance
officer, as well.
If you are unable to satisfactorily resolve the issue
through the available internal channels:
• For Medicare and Medicaid compliance issues, report
your concerns to the Department of Health and Human
Services (HHS), Office of Inspector General (OIG).
• For issues related to state regulations, consider
reporting your concerns to your state ombudsman
programs and/ or your state’s Office of the Attorney
General.
• If you have concerns about your liability or
protections, seek professional legal counsel.
• Contact your national professional association
(American Occupational Therapy Association
[AOTA],
American Physical Therapy Association [APTA], and
American Speech-Language-Hearing Association
[ASHA]) for guidance if you have questions.
Department of Health and Human Services (HHS), Office of Inspector General (OIG)
The OIG is responsible for fraud and abuse prevention, detection, and reporting.
• OIG Website: http://www.oig.hhs.gov.
• OIG Compliance Education Materials: http://oig.hhs.gov/compliance/101 • OIG Spotlight Articles:
http://oig.hhs.gov/newsroom/spotlight/index.asp
• OIG Report Fraud Brochure:
https://forms.oig.hhs.gov/hotlineoperations/posters/OIG%20Hotline%20Ops%20Brochure%20-%20
Professional%20Print%20.pdf
• Stop Medicare Fraud: https://www.stopmedicarefraud.gov/forproviders/index.html
• OIG Compliance Website: http://oig.hhs.gov/compliance/101/
Compliance Guidance for Skilled Nursing Facilities
• Guidance (2000): https://oig.hhs.gov/authorities/docs/cpgnf.pdf
• Supplemental Guidance (2008): https://oig.hhs.gov/compliance/compliance-guidance/docs/
complianceguidance/nhg_fr.pdf
Contact the OIG National Hotline Association Resources and Links
• https://forms.oig.hhs.gov/hotlineoperationsPhone: AOTA Visit http://www.aota.org/About-
(800) HHS-TIPS [(800) 447-8477] Occupational-Therapy/Ethics.aspx
• TTY: (800) 377-4950 ASHA http://www.asha.org/Practice/ethics/
•
Fax: (800) 223-8164
APTA http://www.apta.org/EthicsProfessionalism/
• Mail: Office of Inspector General
U.S. Department of Health and Human Services
NASL http://www.nasl.org
ATTN: HOTLINE
P.O. Box 23489
Washington, DC 20026
