Lost Revenue Series - Part 4

Five Steps to Capture Lost Revenue for Hospital Outreach and Outpatient Services | Part 4: Establish Universal Compliance in RCM

This blog post is part four of a five part series. View Part One, View Part TwoView Part ThreeView Part Five.

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:

  1. Develop risk management goals
  2. Establish written policies, procedures, and standards of conduct
  3. Designate a compliance officer and committee
  4. Conduct relevant training and education
  5. Ensure open lines of communication
  6. Initiate internal monitoring and auditing
  7. Follow disciplinary guidelines
  8. 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.


  • Simple configuration of required claims documentation
  • Payor configurations allow for financial integrity, payor contract adherence, and automated compliance
  • Key compliance rules and logic
  • Template guidance on standard industry documentation


  • Enforces configuration requirements and limits processing/clerical circumvention without approval
  • Required coding and documentation enforced by system workflow
  • Payor billing verified prior to billing patient
  • Workflow to minimize clerical decision-making and unnecessary re-submissions
  • Key compliance alerts/flags
  • Potentially non-compliant actions logged for auditing.


  • Platform resides in a Tier 4 Switch SuperNAP data center (both operations and facility)
  • Armed security
  • Complete data replication and redundant infrastructure
  • SOC 1 Type 2 and SOC 2 Type 2 audited


  • Data resources maintained
  • BI and audit reporting capabilities to strengthen compliance programs
  • Data processing such as front-end editing database
  • Customer support and consulting services to assist client with the use of RCM solution

Audit Trail

  • Source documentation retention for each claim
  • Data and referential integrity maintained for auditing
  • Logging to support customer compliance audits
  • Audit log for system changes

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.

Interested in reading the rest of this series? Subscribe to our blog and get alerted when we cover Part 5, “Promote Patient Access and Physician Engagement.” If you missed the previous posts in this series view them here: Part One, Part Two, Part Three.

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Published by XIFIN
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