Running afoul of regulatory compliance requirements is a significant concern for hospital administrators and finance leaders—with good reason: the consequences can be steep. For example, in June 2020, a Georgia-based hospital system agreed to pay $16 million to settle multiple allegations of violating the False Claims Act and the Federal Anti-Kickback Statute (AKS) statute. In the first issue, case managers allegedly billed Medicare and Medicaid at the inpatient level of care, contradicting physicians’ recommendations for performing procedures at the less expensive outpatient or observation level.
For a broader perspective on compliance oversight, following is a summary of recent outcomes, published by the Office of Inspector General for Health and Human Services.
*adapted from U.S Depoartment of Health and Human Services Semiannual Report to Congress.
While the above activity may look imposing, this screenshot only represents a subset of the full scope of compliance risks faced by health care facilities. Moreover, many of these issues directly relate to revenue cycle management policies and operations, which tend to be a moving target based on the continual flow of patient coverage changes, shifting payor requirements, and regulatory updates.
The bottom line: universal compliance in RCM is paramount to avoid costly compliance ensnarements and penalties, maintain profitability, and ensure long-term viability.
Building an Effective Program
Widely recommended fundamentals of a compliance program commonly adhere to most or all of the following steps:
- Develop risk management goals
- Establish written policies, procedures, and standards of conduct
- Designate a compliance officer and committee
- Conduct relevant training and education
- Ensure open lines of communication
- Initiate internal monitoring and auditing
- Follow disciplinary guidelines
- Take corrective action
Executing these steps will help ensure your organization achieves clear strategic alignment and identifies the right people, processes, and information to begin building an effective program.
Borrowing from enterprise architecture best practices, the successful development and execution of a strategy also requires the right technology (along with people, processes and information). This is particularly important for revenue cycle management based on the scale, complexity, change management, and productivity requirements for RCM operations.
RCM Solution Compliance Capabilities
A robust RCM solution built for compliance should include logic, workflow, audit trail, system, infrastructure, security, reporting, and consulting capabilities outlined as follows.
In many cases, outsourcing billing activities as part of your overall RCM solution can further bolster your compliance footing. When employees manage the end-to-end billing process, decisions on coding, write-offs, and related matters can increase the risk of fraud, waste, and abuse. Certain compensation and management policies can also create unintended incentives for unwanted behavior. Outsourcing billing can eliminate the incentives for fraud, waste, and abuse by removing the rewards and opportunities for errors and transgressions.
Discover more about how we enable our customers to comply with applicable legal and contractual obligations here.