Compliance Program Structure and Governance
Compliance Program Structure and Governance
This domain tests how a healthcare organization builds and governs an effective compliance program: who owns it, how authority and reporting lines work, what the governing body must do, and how the program is documented, resourced, and made operational.
Core rules
- The OIG seven elements are the organizing framework: written policies and procedures; a designated compliance officer and compliance committee; effective training and education; effective lines of communication; internal monitoring and auditing; enforcement and discipline; and prompt response and corrective action.
- The Federal Sentencing Guidelines §8B2.1 stress high-level oversight, a code of conduct, knowledgeable leadership, adequate resources, and incentives for compliance.
- ACA §6401 requires Medicare and Medicaid providers and suppliers to maintain compliance programs as a condition of enrollment; CMS has issued core elements for several provider types.
- Independence is structural, not attitudinal. The compliance officer should have direct, unfettered access to the governing body or its audit committee, with a dotted line to the CEO. Reporting solely to the CFO or general counsel creates a conflict.
- The board must receive regular reports, ask substantive questions, approve the charter and resources, and document oversight in minutes. The compliance committee should be cross-functional: clinical, billing, privacy/security, HR, and operations.
- Charters define authority, scope, reporting cadence, and access to records. Programs must be risk-based and tailored to size, complexity, and service mix.
Worked example
A 12-physician group acquires a billing company and assigns compliance to the billing manager, who reports to the CFO. The board receives one annual memo. Exam reasoning: the arrangement lacks independent compliance leadership, board-level oversight, a compliance committee, and documented risk assessment. A defensible structure separates billing operations from compliance, gives the compliance officer a charter and direct board access, and requires quarterly reporting plus an annual work plan.
Traps that cost marks
- Treating the privacy officer or billing manager as automatically the compliance officer.
- Assuming small practices are exempt from ACA §6401.
- Delegating program ownership to a single department.
- Approving a charter without resources, authority, or reporting cadence.
- Board minutes that show no questions, follow-up, or evidence of oversight.