The nursing home industry is one of the most regulated in the country, and it is extremely likely that government oversight will only continue to increase to further protect patient privacy, improve quality of care, and prevent financial fraud. Long-term healthcare providers need to establish a solid compliance infrastructure now to safeguard the operation’s future - and avoid costly mistakes down the line.

The Role of Healthcare Compliance

The topic of compliance under the healthcare umbrella is a big one, as it encompasses a wide range of state and federal laws and regulations that are constantly evolving. These extend from clinical care requirements at the patient level to the financial aspects of the business, including the coding and billing of medical claims for reimbursement. Providers must adhere to standards set at the federal level through the U.S. Department of Health and Human Services (HHS) and the Office of Inspector General (OIG), The Centers for Medicare & Medicaid Services (CMS), and individual state laws.

While it is easy to get overwhelmed with the complexity of it all, a well-established compliance program exists to detect, mitigate and prevent risks. Organizations that proactively identify weak spots and respond to emerging risks before a problem escalates will be better positioned for long-term viability. On the other hand, providers who fail to take compliance seriously can face any number of consequences, including but not limited to:  

●    Monetary fines
●    Medical liability claims 
●    Increased scrutiny by State or Federal surveyors
●    Placed on a higher level of audit
●    Recoupment of funds back to the insurance payer
●    Unfavorable public survey results
●    Difficulty recruiting new staff
●    Negative public perception 
●    Closure of the facility

Who is Responsible for Compliance?

Providers who are larger in size are more likely to employ a designated in-house compliance officer. Smaller or medium sized providers tend to lean on a team of compliance professionals, which can be in-house or through a third-party consultant such as Richter. Regardless of how the department is structured, the important thing is to ensure that someone holds this responsibility as a priority. But do not be mistaken; while the compliance program should be spearheaded and overseen from the very top, the responsibility of compliance falls on everyone. Every employee should be responsible for the conduct of the organization.

Assessing Organizational Risk

With government oversight and regulatory action on the rise, providers can’t afford not to invest in a comprehensive compliance/risk management plan. This plan should always be unique to the organization, however there are some fundamental tasks that belong in every strategy:
 

1. Organizational Policy & Procedure Reviews

Before any compliance program can prove to be effective, it must be well-documented. Every organizational policy should be reviewed and revised on an annual basis at minimum. Take inventory of all policies, identify any gaps, and archive outdated copies to avoid version confusion. Search and correct commonly made mistakes, such as using “cookie cutter” templates that are not suited for your operation. Strive for policies that are clear and concise, so staff can perform their jobs more efficiently and effectively. This will result in better clinical and financial outcomes. 

2. Communication & Accessibility

Well-written policies mean nothing if they are not communicated and published in a location that is accessible throughout the organization. Verify that the individuals who are responsible for following the policies are aware that they exist and they have easy access to them, preferably in a central location such as a company-wide intranet. Employees can then be held accountable for their actions, and policy updates can be communicated in real time.

3. Training & Evaluations

Employees should be introduced to the organization’s compliance program on day one, and training should remain an ongoing priority. Competency assessments and regular evaluations can provide great insight on areas in need of improvement. With greater understanding of requirements and guidelines, the provider’s technology and industry terminology, providers can minimize violations caused by documentation or other trainable offenses.

4. Internal Monitoring & Auditing

Even with a seemingly solid system in place, it is difficult to know whether an organization’s compliance efforts are effective without frequent check-ins. This can be conducted in various ways, depending on the policy or procedure being monitored. For the claim submission process, for example, a triple check process should be completed for every single claim, to ensure billing accuracy and compliance before submission to the provider. This additional step can help prevent denials and reduce potential loss of revenue, so you can imagine the larger-scale impact when more checks and balances are applied to other areas of the business. 

5. External Compliance Risk Assessment

Some issues are more difficult to detect than others, and a fresh lens may be all your organization needs. Richter’s qualified team of professionals can help you achieve compliance with government rules, regulations, and payer mandates – in both your clinical operations and your revenue cycle.  Our consultants are trained to identify areas of poor performance that are costing you money and inflicting unnecessary risk. In many cases, we can get you back on track in as little as 30 days. To learn more about our risk management solutions, contact us here or call us at 866.806.0799

Enhance Outcomes with Richter

Richter is a trusted industry expert that provides comprehensive solutions including full financial assessments, budgeting, EHR implementation and optimization, ad hoc reporting, reimbursement consulting and even interim management support. When considering an expansion, acquisition, closing or another critical operations decision, our team can weigh in on your options and support you through the entire transition process. To learn more about our flexible solutions, contact us here or call us at 866.806.0799.