Implementing a consistent hospital compliance program is key to cultivating a culture of compliance that minimizes revenue risks, so providers can focus on high-value care.
Healthcare is constantly changing, but one aspect of care delivery that should be consistent is hospital compliance.
A hospital compliance program is key not only avoiding missteps that can result in payment recoupment and even costly investigations but also improving revenue capture and patient satisfaction. Effective programs ensure hospitals and their providers abide by state and federal laws and regulations, as well as payer guidelines. The end result is a smooth billing process for providers and patients.
The programs are integral to high-value care delivery. But developing a hospital compliance program is just the first step. Hospital compliance programs must also be consistent to guarantee providers and their billing teams are aware of ever-evolving and increasingly complex payment rules.
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Hospitals should be regularly engaging compliance teams and performing claim audits to identify weaknesses resulting in missed revenue and areas of opportunity that can boost charge capture and simplify patient billing.
Here are five ways hospitals can ensure consistent compliance programs.
1. Create a multidisciplinary committee
Many hospitals and health systems have appointed a chief compliance officer (CCO) or designated a compliance leader to spearhead compliance efforts and support the organization’s current and future business model. But surrounding the compliance head with a multidisciplinary team is key to a consistent hospital compliance program.
Compliance belongs to everyone in an organization, and as hospitals and health systems expand into new areas of care, experts from across facilities and departments help to ensure compliance with medical billing and coding in unfamiliar areas.
Led by a CCO or other compliance leader, hospital compliance committees should include representation from the C-suite, revenue cycle management, case management, and health information management. The HHS Office of Inspector General (OIG) also recommends that sufficient clinical expertise is on board to provide much-needed frontline experience.
The hospital compliance committee should meet at least quarterly to conduct regular internal audits and develop action plans to ensure the hospital corrects identified weaknesses and execute on opportunities.
2. Write out policies, procedures, and schedules
Having policies, procedures, and schedules detailed in a compliance handbook or other official document is key to program consistency.
OIG advises healthcare boards to establish “a comprehensive policy and objectives to define your quality improvement and patient safety program.” The oversight division of HHS states that the document ensures stakeholders share a common vision for quality at the organization. Incorporating the objectives into employee performance evaluations and incentive compensation can also boost compliance.
This code of conduct helps employees stay compliant and paves the way for compliance committees to perform audits and implement best practices.
3. Perform internal audits
Hospitals and health systems should be engaging a third-party auditor to review medical billing and coding processes, as well as a sample of claims. These third-party audits are key to identifying high-risk areas, workflow inefficiencies, and areas of opportunity. However, the key to staying compliant is an internal auditing strategy.
Organizations should be conducting their own compliance audits to catch inefficiencies and opportunities before the third-party auditor arrives. Internal audits ensure corrective actions resulting from a previous audit are still in effect and can help compliance staff identify new areas at high risk for denial.
In addition to a compliance committee, technology can also help ensure hospitals perform internal audits. Many hospitals still rely on spreadsheets to monitor coding compliance, but technology can streamline that process and identify risk areas that may be invisible to the human eye. The data needed to measure compliance lives on several different IT systems, creating a need for centralized compliance technology.
4. Implement a robust education program
Provider and staff education is the backbone of an effective hospital compliance program, but robust training and education programs are crucial to consistently complying with medical billing and coding rules.
Whether the organization is conducting an internal or external audit, the findings from those reviews need to be shared with providers and other staff members to prevent compliance issues in the future.
Consistent compliance programs provide a wide range of training resources to ensure corrective actions are implemented. For example, compliance staff should over one-on-one training with specific staff or departments if their claims are considered high-risk areas. The education program should also include more general training and resources to encourage staff to stay compliant even when their claims are not at high risk for denial.
Failing to provide a robust education program will lead to persistent compliance problems ever after the compliance committee identifies problems and recommends action. This will also lead to costly rebilling fees and reimbursement delays.
5. Measure compliance program performance
There is always room for improvement, and hospitals and health systems can ensure their compliance programs remain effective by regularly measuring program performance.
Like any area of the revenue cycle, hospitals and health systems should establish key performance indicators to track and monitor compliance performance. OIG provides ways to measure compliance program effectiveness across key elements, including:
- Standards, policies, and procedures
- Compliance program administration
- Screening and evaluation of employees, physicians, vendors, and other entities
- Communication, education, and training
- Monitoring, auditing, and internal reporting systems
- Discipline for non‐compliance
- Investigations and remedial measures
Each section contains dozens of metrics that organizations can use to evaluate their compliance programs. The list is broad to accommodate all types of organizations, but the federal agency suggests that hospitals choose a small number of metrics to track in a given year.
The metrics to be tracked depend on an organization’s individual needs, OIG adds, and the frequency of use should depend on the organization’s risk areas, size, resources, and industry segment.
Every hospital’s compliance program will differ based on a variety of items, but every program should be consistent. Consistency ensures that compliance is not just an activity conducted every year as part of due diligence, but a culture. Developing a culture of compliance is crucial to ensuring a smooth revenue cycle, which allows hospitals to devote key resources to high-value care delivery.
Source: Revcycle Intelligence