Chapter 4: Evaluation Processes, Investigations, and Noncompliance Response

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Introduction to Evaluation Processes, Investigations, and Noncompliance Response

At the core of compliance is the patient. It is a healthcare organization’s duty to ensure that laws and processes are followed to the benefit of the patient and, by extension, the benefit of the community. From the government’s perspective, healthcare compliance programs can reduce or eliminate fraud, waste, and abuse—making compliance programs a sound business decision. A proactive compliance program aims to deter and, in some cases, prevent behaviors contrary to an organization’s code of ethics, policies and procedures, and laws and regulations. There are several ways to assess how a compliance program is performing and how risk areas are being monitored and controlled. Ongoing monitoring, periodic audits, annual program assessments, and external assessments can indicate areas within the organization that need improvement, compliance-related practices that are working, and how the program is faring as a whole.

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