healthcare compliance and integrity

The healthcare system is broader than anyone can imagine. With this broadness and technicality comes the need for regulations and standards.

These set rules and regulations are not just for providers, who must comply with them to ensure professionalism, but also for the security of patients, who could have their lives ruined and their personalities damaged if any of these laws, regulations, and ethical standards were breached.

I mean, how can anyone trust a healthcare system that lacks accountability, credibility, and integrity? It’s pretty impossible.

Hence, the penalty for breaching these set standards and laws can sometimes be severe and, in some cases, result in criminal charges or the suspension of licenses.

While mistakes can’t easily be overturned in the healthcare industry, knowing what to avoid can prevent them from happening in the first place. Here are three common compliance mistakes that healthcare providers should be aware of and avoid at all costs.

Incompetence in Documentation

In any healthcare system, maintaining an accurate and complete record of your patients is essential for their care, continuity, and compliance with standard regulatory requirements.

According to Nicholson & Eastin, LLP, a renowned group of healthcare enforcement action defense lawyer, incompetence in this area of compliance management may result in medical errors, compromised patient safety, potential legal and regulatory issues (as you could be targeted for healthcare fraud), etc.

To avoid this mistake, a healthcare provider must have a robust compliance management system with processes and protocols for efficient record-keeping and documentation. This will help ensure that your patients’ records are complete and accurate.

Your documentation protocol should include documenting patient history, assessments, treatment plans, and any other relevant information. Also, using an electronic health record (EHR) system will make things easier and ensure the integrity of your records.

Neglecting HIPAA Compliance

Do not skip this part! You may think the Health Insurance Portability and Accountability Act (HIPAA) is a common healthcare statute that almost every healthcare provider knows, and compliance is practically universal. So, it’s not something you should concern yourself with while going through this list.

While you’re right, you must understand that having a HIPAA compliance program is totally different from being fully compliant. This is where some providers make mistakes.

They believe having a HIPAA compliance program in place would automatically mean their staff is compliant with the program, and this ignorance and neglect leads to any of the following:

Poor Training of Staff

They fail to train their staff adequately, and these staff, due to poor training, negligently mishandle protected health information (PHI), leading to compliance violations and breaches of patient confidentiality.

Administrative Incompetence

Due to negligence, some health providers fail to implement the necessary physical, technical, and administrative safeguards to protect their patient data.

They underestimate the value of proper policies and procedures in protecting their patient information and fail to conduct frequent risk assessments to see the level of data security vulnerabilities they have.

This lack of security management oversight and administrative incompetence will eventually cost them heavily when investigated for HIPAA non-compliance.

Delay in Reporting Data Breaches

In some cases, negligent healthcare providers may experience data breaches without even knowing it. As a result, the affected patients could have their data in the wrong hands without their consent or awareness.

The delay in reporting such breaches (after the initial 60-day deadline) can lead to significant consequences, like fines and legal actions for the healthcare provider.

To avoid these highlighted HIPAA compliance issues, you must take a different route as a healthcare provider, invest in ongoing staff training, implement strict access controls, conduct regular risk assessments, and have a well-defined breach response plan.

Fraudulent Billing Practices

No one wants to pay for a service that was never offered, nor do they want to overpay for a minor service. The healthcare sector is very complex, and this complexity often makes it hard for an averagely learned patient to know what and why they must pay for a particular service or drug.

To protect them from being scammed, major rules and regulations in the healthcare billing practice were established. While most providers know these regulations and have created systems to ensure strict compliance, some still make mistakes that may lead to them being investigated for fraud and penalized.

A bulk of these mistakes stem from them ignoring the basics, like:


A healthcare provider should not bill more than what was offered during a complex or expensive service or procedure. Some providers do this for higher reimbursement from insurance companies or government healthcare programs like Medicare or Medicaid.

This mistake or intentional act in healthcare can cause financial losses for insurance companies, increase healthcare costs, and potentially harm patients.

When investigated for fraud and found guilty, providers risk losing their licenses, paying huge fines, and being excluded from government healthcare programs.


Some healthcare providers use unbundling to inflate the bill for services rendered to get higher reimbursement from insurance companies or their patients.

They do this by splitting the bill for a particular service or procedure into many components and charging for each of these components.

While these providers may think they can get away with it for now, they will soon have federal agents knocking on their doors, and when found guilty, they will be penalized heavily.

Billing for Medically Unnecessary Services

Some providers intentionally and fraudulently (with exceptions) bill their patients for medical services, tests, or procedures that are not medically necessary.

They do this to inflate the cost of diagnosing and treating their patients, inadvertently putting them under pressure and potential harm.

This is a fraudulent billing practice that every professional healthcare provider should avoid at all costs.

Phantom Billing

A provider should not be billing a patient for a service never provided. However, some healthcare providers do this out of mistake, and others intentionally.

They add services they never rendered to a patient’s billing costs to inflate the reimbursements they’ll get from insurance companies or their patients. This act is fraudulent and unprofessional.

As a healthcare provider who is intent on avoiding these fraudulent billing practices, you must

  • Implement a stringent billing and coding procedure.
  • Conduct regular audits.
  • Ensure your staff is well-trained in compliance and ethical billing practices.

Plus, you must seek legal advice and compliance guidance when implementing a new billing protocol to avoid unintentional billing errors that could lead to legal consequences.

Wrapping Up

As a healthcare provider, you serve as a bridge between patients seeking quality healthcare services and the ethical, compliant, and patient-centered delivery of care, ensuring their well-being and trust.

Your commitment to upholding these standards of healthcare compliance not only safeguards your practice but also contributes to the overall integrity of the healthcare system, benefiting your patients and you.