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Reality versus Perception

By Carol Miller RN MHA

Carol S. MillerThere are many associated benefits of a healthcare or medical practice compliance program, some of which are only perceived whereas others are very definitive.  Most providers try to comply with the rules and regulations and what is or is not covered by different insurance programs.

Risk Management and Quality Initiatives

Regardless of their ethical and quality processes in their office practice, the decision to develop and implement a compliance program still is an important and needed business decision.  The processes involved in a compliance program can help improve the organization’s performance by providing basic principles in quality improvement which can help improve the provider’s bottom line.

The Benefits

Several benefits of a compliance program are:

  • Improving the quality of patient care
  • Servicing as a resource for information about compliance-related issues
  • Saving time, money, and associated apprehensions during audits or reviews
  • Preventing or identifying improper conduct with systems for evaluation and correction
  • Providing training for employees and contracted services to recognize fraud and abuse
  • Providing a way for employees to report potential problems
  • Demonstrating to staff and community that the practice is committed to honesty and appropriate conduct
  • Minimizing loss associated with false claims through early recognition and reporting, and decreasing the provider’s exposure to civil penalties, sanctions and other administrative actions, such as exclusion


The OIG has developed a series of voluntary compliance program guidance documents directed at various segments of the healthcare industry, such as hospitals, nursing homes, third-party billers, durable medical equipment suppliers, clinical laboratories, home health agencies, hospices, nursing facilities, ambulance suppliers, pharmaceutical manufacturers, physician practices, and others, to encourage the development and use of internal controls to monitor adherence to statutes, regulations and program requirements.




Fraud and Abuse, Too!

The OIG documents also identify fraud and abuse risks to watch out for when creating a programs


Ms. Carol S. Miller has an extensive healthcare background in operations, business development and capture in both the public and private sector. Over the last 10 years she has provided management support to projects in the Department of Health and Human Services, Veterans Affairs, and Department of Defense medical programs. In most recent years, Carol has served as Vice President and Senior Account Executive for NCI Information Systems, Inc., Assistant Vice President at SAIC, and Program Manager at MITRE. She has led the successful capture of large IDIQ/GWAC programs, managed the operations of multiple government contracts, interacted with many government key executives, and increased the new account portfolios for each firm she supported. She earned her MBA from Marymount University; BS in Business from Saint Joseph’s College, and BS in Nursing from the University of Pittsburgh. She is a Certified PMI Project Management Professional (PMP) (PMI PMP) and a Certified HIPAA Professional (CHP), with Top Secret Security clearance issued by the DoD in 2006. Ms. Miller is also a HIMSS Fellow.

CASE MODEL: Compliance


The documents provide principles to follow when developing a compliance program that best suits the organization’s needs.


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