Like Oil and Water: Compliance and Operations Do Not Mix

Chris Conway

Manager

Aegis Compliance and Ethics Center, LLP

Like Oil and Water: Compliance and Operations Do Not Mix

Accurate job descriptions and titles are important for a health care organization. An effective job description communicates an individual’s primary job function, the skills and experience necessary to perform the job, and helps establish a chain of command. An employee’s job title should reflect their job description, highlighting the employee’s organizational rank and principal purpose. In a health care organization, it is best practice to keep compliance and operations separate and distinct from one another. Job titles should reflect this distinction and clearly differentiate between individual’s performing compliance and operations functions.

The Difference between Compliance and Operations

Health care compliance and operations departments perform different, but equally important, tasks within an organization. The Department of Health and Human Services (HHS) defines health care operations as certain administrative, financial, legal, and quality improvement activities that are necessary to run an entity’s business and support the core functions of treatment and payment. These activities include case management, care coordination, business management, and general administrative activities. In short, operations involve the day-to-day management of activities that allow a health care organization to run. The intake coordinators registering the patient, the patient care coordinators creating a care plan, the doctors and nurses administering care, and the finance department sending the claim out to the appropriate payor – all are involved in operations.

A compliance department should ensure that all legal, ethical, and professional standards are met or exceeded within the health care organization. The legal and regulatory framework that governs the health care industry is administered and enforced by a myriad of federal and state agencies. A compliance department contains specialists who parse through the dense rules and regulations and ensure they are adequately followed. Compliance departments develop policies and procedures for operations employees, educates and trains the operations employees of their ethical and legal responsibilities, monitors and audits to ensure the operations employees follow applicable standards, enforces standards through well-publicized disciplinary guidelines, and responds promptly to detected offenses and undertakes corrective action. An effective compliance program is not static; it requires constant updating and fine-tuning.

The day-to-day management of a health care organization requires full-time operations employees. Administering an effective and dynamic compliance program similarly presents a full-time job for compliance employees. For each portion to operate at an optimal level, operations and compliance departments should be separate and distinct from one another within a health care organization.

How does this Involve Job Titles?

Recent research suggests that job titles create an important vehicle for identity expression. Employees tend to embody their job title and focus their energies toward fulfilling the underlying job description. An employee with an operations focused job title will concentrate on operations, and an employee with a compliance focused job title will concentrate on compliance. Consider the hypothetical job title “Director, Billing Administration and Compliance.” This job title suggests the employee must oversee the health care organization’s day-to-day billing enterprise while also administering and enforcing a robust billing compliance program. Expecting one individual to adequately fulfill both tasks is wholly unrealistic and detrimental to the organization.

Job titles also help establish reporting relationships in an organization. Employees are likely to bring compliance concerns to those with “Compliance” in their job title. Again, consider the hypothetical job title “Director, Billing Administration and Compliance.” Employees may present compliance questions to this individual who likely lacks the requisite authority and knowledge to rectify any issues. Such billing compliance problems are better investigated and corrected by the independent compliance department sitting outside of operational functions.

Operations and compliance should be distinct from one another within a health care organization and conflating the two concepts in job titles leads to decreased performance and confusion. The compliance department should remain outside of operations to advise, educate, investigate, and audit/monitor operational activity. All job titles within a health care organization should reflect this distinction.

 

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