The business of diagnostics and health systems gets more complicated all the time, and the increasing complexity of your company’s compliance obligations can at times seem overwhelming. If you manage revenue operations or work in finance, you know how to support your company’s compliance program, but you may not be aware of all the challenges your compliance department faces or how you can proactively help surmount them or unintentionally add to them.
Some of the most challenging compliance obligations your company has arise from legal requirements intended to deter fraud, waste, and abuse in health care programs. You know that you have to code correctly, and bundle codes correctly for the programs covering your services. You know that each government program and each commercial payor can have its own requirements for documentation, and you have to properly maintain that documentation. You have to keep up with changes in the requirements of each government program and each commercial payor.
You have to avoid creating the wrong incentives. You have to bill and collect payments in accordance with the many laws that apply to this area, including the recently enacted federal legislation Eliminating Kickbacks in Recovery Act of 2018 and its requirements for accurate invoicing and limitations on waiving co-payments and deductibles. You have to train your personnel and monitor their activities and remediate any noncompliance you may find.
Compliance requirements keep changing, and a misstep can result in lost revenues, fines, and even extreme penalties like debarment, corporate integrity agreements, and criminal consequences for your company and responsible individuals. How can you keep up? How can you support ever-increasing compliance obligations when your budget and staffing are not keeping pace? As a revenue or finance leader, how can you better support your compliance team?
Expect your vendors to do their share to help your compliance efforts. Do you use revenue cycle management software that makes your compliance activities easier? Not all revenue cycle management (RCM) solutions are equal.
Below are a few questions to ask of your RCM vendor:
Does it maintain a first-rate, highly secure environment? Does it include data sources that update key codes and billing information to get your claims processed correctly and in compliance with applicable requirements? Does it provide automated support for required documentation, logging, and recordkeeping?
Is it configured to comply with the ever more restrictive rules around managing co-payments and deductibles?
Have you considered outsourcing all or a portion of your billing activities? When your own employees manage the entire billing process, decisions on coding, write-offs, and other billing matters can increase the risk of fraud, waste, and abuse. Your compensation and management policies may create unintentional incentives for bad or careless behavior. Outsourcing billing activities may reduce the incentives for fraud, waste, and abuse by eliminating the rewards and opportunities for bad or careless behavior.
Maybe it’s time to review your revenue cycle management software and billing and collection activities, and determine whether they are helping your compliance program, or just creating more challenges.