Harmony Healthcare International (HHI) Blog

Compliance Series - 7 Elements: #1 Policies and Procedures



Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency • Survey


policy-procedure-street-301082-edited.jpgAs a continuation of last week’s blog post, we are reviewing the seven elements of an effective Compliance Program.  To reiterate, it is necessary to develop and implement a Compliance Program with the following key elements: 


  1. Policies and Procedures
  2. Reporting and Investigating
  3. Education and Training
  4. Prevention and Response
  5. Auditing and Monitoring
  6. Responsibility/Oversight of Compliance Officer/Committee
  7. Enforcement, Discipline and Incentives

Today’s blog post will focus on #1 Policies and Procedures: 

The following narrative is not uncommon to hear from Compliance experts in the industry: 

“Policies and Procedures must be a living document. It is not a binder on the shelf that remains unopened. ” 

What does this really mean? The above quote portrays the importance that every healthcare organization must develop facility specific protocols that define the rules of engagement for the operations to detect, deter and mitigate fraudulent activity. In addition, these Policies and Procedures are dynamic, refined and current with the changing landscape related to regulatory, reimbursement and technological changes.  For example, the innovation of cell phones with readily accessible camera functionality spurred a wave of HIPAA violations across the nation.  Skilled Nursing Facilities immediately responded with additional policies on the parameters for employee, resident and visitor cell phone usage.  This situation exemplifies the importance of the dynamic, refined and current policies and procedures.

Patient-Driven Payment Model (PDPM)

Another example is the Policy and Procedures for Transmitting MDS Assessments timely to the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. If the Medicare Administrative Contractor (MAC) queries a PPS MDS for a claims review and identifies that the MDS was NOT successfully transmitted and accepted in the QIES system, this will result in a technical denial with provider liability (i.e., no reimbursement or right to appeal).

As you and your staff navigate through the Policy and Procedure seas, please allow Harmony Healthcare International (HHI) to guide you on some relevant tips.  The initial steps for any Policy and Procedure Manual is the outline (Table of Contents).  Below is a sample start of an outline: 

Start of a Table of Contents

  • Arrangements with Health Care Providers Involving Patient Referrals
  • Beneficiary Inducements
  • Billing
  • Gifts
  • Health Care Professional Credentialing
  • Privacy and Security of Protected Health Information
  • Record Keeping and Documentation
  • Refund of Overpayments
  • Responding to Government Investigations
  • Vendor Agreements
  • Audits and Monitoring

    • Billing and Documentation
    • Contract Review
    • Controlled Substance Inventory
    • Personnel Documentation Review
    • Billing:  Medicare Part A (Triple Check)
    • Billing:  Medicare Part A (Therapy Documentation)
    • Billing:  Medicare Part B (Therapy Documentation) 

In closing, here is a question for you to ponder.  
What is the first Policy and Procedure that must be implemented before any other?


The answer:
Non-Retaliatory Policy and Procedure

Harmony Healthcare International (HHI) is available to provide assistance You can contact us by clicking here. Looking to train your staff?  Join us in person at one of our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

harmony20 October 29-30 2020 Encore Boston Harbor

Topics: Compliance

Kris Mastrangelo, OTR/L, LNHA, MBA


Kris Mastrangelo, OTR/L, LNHA, MBA

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