Considering healthcare is such a huge industry, it should be no surprise that it is heavily regulated, with stiff fines for those who break the rules.
Almost everything is subject to rules and guidelines, including safeguarding patient information, following safety precautions while dispensing medications or performing operations, recording treatment accurately and entirely, and appropriately coding and paying.
What Do You Mean By Healthcare Compliance?
Healthcare compliance is adhering to all applicable legal, professional, and ethical standards in healthcare. It’s all about following the rules, and healthcare has a lot of them. Regulations of this complexity are always evolving, necessitating operational and workflow adjustments and regular training and auditing on top of other activities.
It applies to all healthcare companies, regardless of their size. When establishing a secure, efficient, and reliable environment, GRC is essential to the holistic approach.
Who Governs Healthcare Compliance?
Numerous federal and state entities oversee compliance with health regulations. It is not uncommon for federal agencies to work together to regulate the production and distribution of medication. They ensure that drugs, biologicals, and medical equipment are safe and effective. Aside from that, the FDA serves as a reliable source of information for the general public.
Healthcare organizations are audited by the Office of Inspector General (OIG) and the Department of Health and Human Services (HHS) to prevent waste and fraud. As part of its annual Work Plan, the Office of Inspector General informs companies about potential audits they may face by announcing the specific subjects it plans to focus on that year.
Moreover, the OIG and HHS offer a wide range of instructional tools to help healthcare firms stay on top of healthcare regulations and guidelines.
How Can Healthcare Providers Guarantee Compliance?
In addition to preventing costly and time-consuming investigations and payment recoupment, a hospital compliance program is essential for increasing revenue and patient satisfaction.
Effective programs guarantee that hospitals and their providers adhere to state and federal laws and regulations, payer guidelines, and the highest standards. Providers and patients benefit from a streamlined billing procedure.
The programs are essential to delivering high-quality care, and a hospital compliance program is only the first step in ensuring patient safety. As payment laws change and become more complex, hospitals’ compliance programs must also be updated to reflect these changes.
If hospitals aren’t engaging compliance teams and conducting claim audits, they’ll miss out on revenue and opportunities to streamline patient billing.
Hence, healthcare compliance solutions should include the following five components.
1. Set Up An Expert Committee From Various Fields
Due to many medical facilities, health systems have entrusted compliance oversight to a chief compliance officer (CCO) or other designated compliance leader. However, it is critical to surround the compliance director with a multidisciplinary team to maintain a consistent hospital compliance program.
Every employee in a business is responsible for ensuring that medical billing and coding regulations are followed, and this is especially important when hospitals and health systems expand their services.
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The C-suite, revenue cycle management, case management, and health information management should all be represented on hospital compliance committees led by a CCO or other compliance leader. There should be enough clinical expertise on board to provide much-needed front-line experience, according to the HHS Office of Inspector General (OIG).
For the hospital to fix any deficiencies and take advantage of any possibilities, the hospital’s compliance committee should meet at least twice a year.
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2. Document A List Of Guidelines, Processes, And Deadlines
The consistency of a program relies heavily on having policies, processes, and timetables spelled out in a compliance handbook or other formal document.
According to OIG’s advice to healthcare boards, a detailed policy and objectives to describe your quality improvement and patient safety program should be established. According to HHS’s oversight division, the document ensures that the organization’s stakeholders share a consistent vision for quality. Compliance can be improved by including the objectives in staff performance assessments and incentives.
This code of conduct enables compliance committees to conduct audits and establish best practices by ensuring that all employees adhere to the rules.
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3. Conduct Internal Audits
Having a third-party auditor check medical billing and coding processes and a sample of claims is a good idea for hospitals and health systems. To uncover high-risk regions, process inefficiencies, and opportunities for improvement, third-party audits are crucial. Nevertheless, a systematic approach to internal auditing is essential for ensuring compliance.
Before a third-party auditor arrives, organizations should undertake compliance audits to identify inefficiencies and possibilities. To check that corrective measures implemented following a previous audit are still in place, internal audits are useful for compliance officers looking for new areas of high risk for rejection.
An internal audit committee isn’t the only way to verify compliance: technology can also help. Technology can speed the coding compliance monitoring process and highlight risk areas that may be invisible to the human eye. Many hospitals still rely on spreadsheets to do this. There is a need for centralized compliance technology since the data required to measure compliance is spread across multiple IT platforms.
4. Develop A Comprehensive Educational Strategy
An effective hospital compliance program is built on the education of providers and employees. Still, it is critical to have well-developed training and education programs to ensure that medical billing and coding laws are constantly followed.
A company conducting an internal or external audit must discuss the results of those assessments with providers and other employees to avoid future compliance problems.
A wide range of training tools is available through consistent compliance programs to ensure the implementation of corrective actions. In cases where their claims are deemed high-risk, compliance professionals should conduct one-on-one training with specific organization members or departments. More general training and materials should be included in the education program to encourage employees to remain compliant even when their claims are not at high risk of denial.
Even once the compliance committee discovers and proposes corrective action, a lack of a thorough education program will lead to ongoing compliance issues. Rebilling expenses and refund delays will be incurred as a result of this.
5. Monitor The Efficiency Of Your Compliance Program
It’s always possible to improve, and healthcare organizations can keep their compliance programs effective by constantly evaluating their results.
Key performance indicators should be established for hospitals and health systems to track and monitor compliance performance. Standards, policies, and procedures, compliance program management, screening and evaluating workers, physicians, and vendors, monitoring and auditing, and internal reporting systems are just a few ways OIG makes it possible to assess the performance of a compliance program.
There are dozens of metrics in each segment that can assess a company’s compliance program. Although the list is extensive, the federal body recommends that hospitals focus on a few criteria each year.
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In The End
Many factors go into a hospital’s compliance program, but they should all be the same. It is important to maintain a consistent approach year after year to make compliance more than a one-time event as part of an annual audit.
Making sure the revenue cycle runs smoothly helps hospitals focus their resources on providing high-quality treatment and improving patient outcomes.