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Must-Have Compliance Capabilities to Manage Risk and Help Drive Growth

  • Chief Legal and Compliance Officer, XIFIN, Inc.

Thorough RCM processes address a myriad of compliance issues that can cost an organization money, business freedom, and even exit opportunities. Compliance requirements are continually changing, and any misstep could result in lost revenue, fines, and even extreme penalties such as debarment, corporate integrity agreements, and criminal consequences for the company and responsible individuals. 

The federal government continues to aggressively enforce compliance requirements and state-by-state legislation and commercial payor contracts can also have restrictions on compliance violations. It is difficult for any single laboratory or other diagnostic provider to keep up with the changes.

Laboratories need to maintain effective compliance programs that adhere to applicable laws and as a necessary risk mitigation strategy. There are seven key factors that together comprise an effective compliance program:
  1. Standards and Procedures
  2. Oversight
  3. Due Diligence
  4. Communication, Training & Education
  5. Internal Monitoring and Auditing
  6. Enforcing Standards
  7. Responding to Issues

If you are moving toward a comprehensive RCM solution, the supplier you choose should have compliance capabilities built into the logic and workflow, enable an audit trail, have a highly secure system and communications, and have a strong business continuity plan.


  • 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


  • Enforcing configuration requirements and limiting processing and/or clerical ability to circumvent those requirements without management input
  • Applying required coding and documentation via system workflow
  • Designing workflow to optimize payor billing prior to billing patient
  • Minimizing clerical decision making and unnecessary re-submissions
  • Alerting, flagging, and logging potentially non-compliant actions for audit logs and review

Audit Trail

  • Retaining source documentation for each claim
  • Maintaining data and referential integrity for auditing
  • Logging to support customer compliance audits
  • Updating audit log for system changes


  • Using top-tier data centers
  • Backing up and archiving designed to achieve recovery objectives
  • Securing communications
  • Basing security measures on NIST cyber-security framework
  • Complying with privacy and security standards and requirements


  • Maintaining data resources
  • Strengthening BI and audit reporting capabilities
  • Processing data such as front-end editing database
  • Assist clients with the use of their RCM solution through customer support and consulting services

Outsourcing all or a portion of your RCM activities can assist with maintaining compliance. 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.

To learn more about how XIFIN helps customers reduce their compliance risk, click here:

Published by XiFin
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