Financial Crime World

Here is the rewritten article in markdown format with proper headings, subheadings, and bullet points:

Sample Risk Assessment and Compliance Program for Healthcare Organizations

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Vulnerability Criteria

The document outlines a vulnerability criteria system with three levels of risk: High, Medium, and Low. Each level has specific characteristics.

High-Risk Level

  • No method for anticipating and assessing specific risk events exists.
  • Manual processes with many data transfer points and owners.

Medium-Risk Level

  • A method for anticipating and assessing specific risk events exists, but issues are not effectively escalated to the appropriate executives.
  • Automated processes encompassing multiple systems and owners.

Low-Risk Level

  • Controls are appropriately preventive and detective, and there is effective reporting.
  • Automated processes with integrated systems.

Compliance Risk Universe

The document lists various compliance risks areas:

  • Hospital 0 (no risk)
  • Billing Practices
  • Medically unnecessary services
  • Upcoding or DRG creep
  • Outpatient services rendered in connection with inpatient stay
  • Teaching physician and resident requirements
  • Credit balances
  • Anti-kickback
  • Stark physician referral

Conducting the Risk Assessment

The document outlines a process for conducting a risk assessment, which includes:

  1. Identifying, analyzing, and managing risks relevant to objectives.
  2. Considering the risk’s significance, likelihood of occurrence, and how they should be managed.
  3. Management may initiate plans, programs, or actions to address risks or accept the risk due to cost or other considerations.

Data Sources

The document lists various data sources for conducting a risk assessment:

  • Survey front-line managers
  • Interview senior and middle management
  • Review available reports (CMS inquiries, OIG inquiries, RAC results, etc.)
  • OIG Workplan

Sample Process

The document outlines a sample process for conducting a risk assessment, which includes:

  1. Interviewing senior leadership.
  2. Surveying front-line managers on risks related to their area of accountability.
  3. Summarizing interview and survey results by department.
  4. Meeting with senior management to assign risks to a “heat map”.

Suggested Questions for the Board

The document suggests questions that the board may ask:

  • How is the compliance program structured and who are the key employees responsible for its implementation and operation?
  • How does the organization’s compliance reporting system work?