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Healthcare Compliance

Healthcare Compliance | Healthcare and Technology news | Scoop.it

Developing a comprehensive compliance program is no longer optional for healthcare providers. Successful Compliance programs provide protections for provider entities, and patients alike. There is no single “best compliance” program. Providers with limited resources must still develop and maintain an active compliance program. Larger organizations may have entire departments dedicated to maintaining compliance standards. Healthcare providers compliance programs should be customized to each entity, based on the identifiable areas of risk. The OIG adoption of the underlying principles to provide a baseline of compliance structure that can be adjusted to the specific needs of the organization. At a minimum compliance programs should:

  1. Establish clear internal guidelines in the form of published policies and procedures relative to billing, staff behavior, and patient protections.
  2. Provide an atmosphere in which employees are free to report potential compliance issues in an unfettered risk free environment.
  3. Identify a Compliance Officer who maintains overall responsibility for the entities compliance and reporting processes.
  4. Establish strict management and control over protected patient health and financial records.
  5. Ensure technologies are in place to monitor compliance efforts and programs with the organization.

Creating Compliance Programs

Compliance programs impact the entire spectrum of a facilities financial and clinical operations.  As such it is important to develop an appropriate structure of policies and people to administrate, provide advice and ensure adherence to published compliance regulations.  Creating a compliance structure will not eliminate Audits, but can provide additional levels of protection for the providing facility.  Identifying the correct staff to implement the compliance program is the first of several steps.  Developing a compliance structure includes adherence to CMS billing standards, coding accuracy, and accurate translation of health records to the Revenue Cycle solution.

Maintaining a Compliance Program

As regulations change, facilities must adapt and evolve their internal governance processes.  Billing regulations change frequently requiring providers to stay on top of the latest software revisions, as well as monitoring the changing “code sets” that enhance the billing process.  A good compliance program will include a clearly defined process of systems maintenance and staff re training.  Staying current on the latest compliance trends is an integral part of any compliance program.

Compliance Audits

Compliance audits are among provider’s most stressful activities.  As such providers must have a clearly defined audit process.  The process must include timely provision of requested patient records/charts that are fully completed, uniform in presentation, and clearly and consistently labeled.  Having a solid compliance program in place and in practice will prepare a client well for any audit activity.

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Practices Should Prepare for Payer Consolidation

Practices Should Prepare for Payer Consolidation | Healthcare and Technology news | Scoop.it

We live in a very exciting time in the healthcare industry. Regardless of how you feel or think about decisions that are made on the government level, healthcare is in a period of controlled chaos right now.


With the potential merger of Anthem and Cigna and Aetna and Humana, or Assurant closing its doors on its health insurance business, things are about to get really interesting for medical practices. Arming yourself with as much information as possible is key to not just surviving financially, but thriving in this new environment.

Let's take Assurant, for example. They've decided that doing business in the healthcare arena and competing against the dominant healthcare insurance companies was far more expensive than expected. What does this mean for your practice? If you have patients that use Assurant as their medical insurance, it's a great idea to step in and take control of those accounts, now. Create a waiver for Assurant patients that explains what is going on, what to expect from their plan, and how they can still see you with a new insurance plan. The waiver should also state that in the event Assurant does not pay the medical claim, patients will be responsible for the allowed amount, and they will have to pay out of pocket if it is a PPO Plan. If the plan is an HMO, and Assurant does not pay, the practice is not allowed to place a PR (patient responsibility) to the patient and will lose that money.


Aetna and Assurant have similar fee schedules, so suggest to your patients to look into individual Aetna plans, to ensure that you will retain those patients and not lose revenue if you are contracted with Aetna. You will also need to really follow up with those claims and make sure that Assurant is paying you. I have seen them use a delaying tactic of denying a claim with the code CO95 (plan procedures not followed), which basically means they are sending your claim to a different claim address than what was provided to you at the time of benefit verification.  


As far as the pending mergers, I really love it when this happens. I'm particularly fond of the companies that have been courting each other lately. With the possible Aetna/Humana merger, Aetna will be able to add a lot more patients to their network. It will position them as a real player and earn them much needed respect within the market. I still have some overall issues with both Aetna and Humana, but merging them together should ease some of those issues.


The Anthem/Cigna cat-and-mouse game going on is particularly interesting. Cigna claims they're worth more than $184/share, and said no to Anthem's last purchase attempt. But Anthem is not giving up. Cigna used to be a premium plan until they teamed up with American Specialty Health. They have basically cut reimbursements to providers in half (if you signed up under their new network, otherwise you are seeing Cigna patients out of network), and implemented a time-consuming authorization process that eats away at whatever profit your practice may have left over from the reimbursement cuts. They implemented this over the course of the last year, or so. Working with Anthem is pretty cut and dried: What you see is what you get, with no hidden agendas. Anthem requires few to no pre-authorizations, allowing you to see your patient and maybe make a few bucks.


Just taking a few moments and reading up on what is going on in the healthcare industry today is really key to insuring your practice is not caught off guard. Always be learning, always be aware. There are multiple newsletters you can sign up for that will drop a daily or weekly e-mail into your inbox that will help you keep up.

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