Compliance Programs after The Affordable Care Act

Many view The Patient Protection and Affordability Care Act (“Act”) as legislation that primarily expanded insurance coverage for the uninsured.   The major provisions of this “Act” do focus on insurance expansion, however, the reform provisions of this “Act” include revisions and requirements for healthcare organizations’ compliance programs and activities.   These provision while receiving little or no media attention or health policy discussions are a Congressional attempt to weed out the billions of dollars of waste in our healthcare system.  Some experts indicate that this waste accounts for 100 billion of dollars lost each year to fraud and abuse in our healthcare system.

Historically, The Department of Health and Human Services, Office of Inspector General has published guidance to individual sectors of the healthcare field.   This guidance provided the framework for voluntary compliance programs for the healthcare industry.   The “Act” requires, for the first time, mandatory compliance programs to mitigate healthcare fraud and abuse.

This presentation will discuss and describe these provisions embedded in the Affordable Care Act.   The authors will also analyze the impact on the healthcare system and healthcare organizations.  The paper concludes with specific recommendations to the field for implementation of the compliance requirements of this “Act.”  Also, discussed are the gaps in requirements that remain for compliance-related mandates and recommendations for potential Congressional action.