The guidelines further outline that “due diligence and the promotion of an organizational culture that encourages ethical conduct and a commitment to compliance with the law ... minimally require" seven elements:
1. Compliance standards to prevent and detect criminal conduct
2. High-level responsibility for and board oversight of the compliance and ethics program
3. Trustworthy individuals (reasonable efforts are made to ensure individuals who have engaged in illegal activities or other conduct inconsistent with an effective compliance and ethics program are not employed by the organization)
5. Monitoring and auditing
6. Enforcement and discipline
7. Response and prevention
It is essential, then, that ASCs establish and implement monitoring and auditing procedures which demonstrate center employees have received adequate training and education on the organization’s compliance standards (e.g., code of conduct, policies and procedures) and are participating fully in an organizational culture that strives to conduct business ethically with a strong commitment to, and observance of, the laws governing its operations. Satisfying the monitoring and auditing requirements is best served via a combination of internal reviews and external audits.
Internal reviews are conducted by individuals within the organization to ensure established policies, procedures and processes are being adhered to by
employees. Some of the areas ASCs may want to consider reviewing include –
• Evaluation of the accuracy of the verification/registration process
• Compliance with HIPAA Privacy & Security Rules
• Adherence to policies related to upfront (over-the-counter) collections
• Proper observance of separation of duties and handling of cash/credit card transactions
• Assessment of whether monies deposited to the bank tie out to payments posted
• Observance of write-off policies
• Assessment of credit balances to ensure timely processing of same and preserve the integrity of accounts receivable
Findings should be shared with center personnel to highlight areas that are being performed with a high degree of consistency, as well as those requiring improvement. Focused performance improvement studies should be undertaken to (1) empower staff to analyze where policy misunderstandings have occurred and/ or when processes broke down, (2) implement processes that effectively deal with the problems identified, and (3) periodically reassess progress until a consistent trend of goal achievement has been attained.
Ensuring your ASC is on target administratively, clinically and financially isn’t easy. It is helpful to ensure that some of your center’s monitoring and auditing occurs via external reviews which can point out organizational blind spots that insiders may be unable to detect about the practices within their own organization.
Consider this scenario. You “know" you have hired honest and loyal staff members, have put comprehensive policies and procedures in place, and are “certain" processes are consistently adhered to by all. However, you may also make allowances for staff members because of how well you know them. “Julie really went through a tough time for a period of six months – her mother passed away, she had to move her father into an assisted living facility, and her husband lost his job. It’s been tough for her to stay focused at work, but she’s definitely getting back up to speed. I don’t know if anyone with two kids in college would have been able to handle all of those stressors any better than she did. She was great, actually. She stayed late a couple days a week and came in on the weekends. She absolutely wouldn’t let anyone else cover her job duties even though we offered to bring in outside assistance. She’s that kind of person – always taking care of everybody else, never burdening anyone with her problems." Would you be surprised to find out that Julie’s longevity with the company coupled with insufficient internal controls and her sudden increased financial burden created the perfect storm? She started “borrowing" a little money from the business, intending to repay the funds as soon as her family got back on its feet. When she realized her “borrowing" might be detected because her repayment plan wasn’t occurring on her original anticipated schedule, she began using the company’s credit card to purchase food and essential supplies for personal use. It took an outsider’s review to uncover Julie’s embezzlement and misuse of organizational resources.*