Insights
Navigating the complex landscape of healthcare compliance
Cheryl Duva, Chief healthcare strategist, UST Evolve
Achieving compliance is a constant challenge in the ever-evolving landscape of healthcare regulations. By leveraging centralized solutions and AI-driven automation, healthcare organizations can proactively tackle compliance issues, mitigate risks, and transform regulatory adherence from a costly burden into a valuable strategic advantage.
Cheryl Duva, Chief healthcare strategist, UST Evolve
Healthcare organizations face a daunting task in adhering to the intricate web of Medicare and Medicaid compliance regulations. The knowledge required to navigate this complex terrain often resides with a select few individuals, making it challenging to ensure consistent compliance.
"Maintaining compliance with all the policies, regulations and requirements is incredibly arduous," said Cheryl Duva, chief healthcare strategist at UST Evolve.
Compliance rules range from substantive healthcare policy issues, operational updates, and technical clarifications to font size and reading level requirements for documents.
Noncompliance can happen “unbeknownst to anyone in the organization until an audit is done. And that’s when you don’t want a surprise because you can’t undo it.”
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Challenges of healthcare compliance
The recent CMS Interoperability and Prior Authorization Final Rule, CMS-0057-F, adds more complexity to healthcare compliance. This rule, among others, requires organizations to follow over 50 new regulations.
Duva highlights five key challenges healthcare companies face:
- Limited knowledge sharing: Compliance knowledge is often concentrated within a small group of employees, making it difficult to disseminate and maintain.
- Frequent regulatory changes: Medicare and Medicaid frequently update forms and templates without proper notification.
- Steep penalties: Noncompliance can result in significant fines, impacting financial health and reputation.
- Contractual implications: Compliance issues can hinder contract renewals and new business opportunities.
- Increased audit risk: Noncompliance increases the likelihood of future audits, increasing the burden.
Frequent updates to healthcare laws, regulations and policies necessitate continuous monitoring and adaptation of compliance programs to mitigate risks and challenges.
Left unsolved, these challenges collectively cost healthcare organizations hundreds of hours and millions of dollars in compliance fines. Periodic audits and monitoring are time-consuming and resource-intensive and simply not enough to meet the challenges.
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Simplifying healthcare compliance
Duva envisions a centralized "source of truth" to address these challenges. This repository would house all relevant compliance information, updated in real-time through AI and machine learning: “I want to turn the old compliance culture from a burden into a benefit via tech-enabled compliance modernization.”
Critical components of this solution include:
- Compliance knowledge management: A central location for all compliance information powered by AI and ML.
- AI-powered form retrieval: Automated retrieval of the latest Medicare and Medicaid forms.
- Template automation: AI-driven generation of communication templates to ensure compliance.
“When government contractors want to know what needs to be done for a specific topic, they should be able to key into that central repository and immediately see a summary of the most up-to-date requirements, along with impact to various departments within their organization.”
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Compliance as a Service
By subscribing to a Compliance as a Service solution, healthcare organizations can benefit from:
- Reduced costs: Avoid costly fines and penalties
- Improved efficiency: Free up employees to focus on core competencies
- Enhanced member satisfaction: Minimize compliance-related issues that can lead to member dissatisfaction
“Being non-compliant causes tremendous member abrasion. Members complain and call their senators, congresspeople and regulators, and it gets ugly real fast. This healthcare compliance solution would lessen the risk and the cost.”
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Proactive compliance monitoring
Duva emphasizes the importance of proactive compliance monitoring. Machine learning can generate alerts based on specific behaviors, such as increased service calls, indicating potential compliance issues.
For example, there may be a jump in calls to a healthcare plan’s customer service number. These extra calls are logged with a specific complaint code. The code triggers an alert about an emerging issue the company can handle before any healthcare compliance audit.
“And that’s really the ultimate goal. Finding out about an issue in near real time allows you to fix it right away.”
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Leveraging technological advancements
An unlikely culprit helped create the environment for building tech-enabled solutions to simplify compliance logistics. The COVID-19 pandemic accelerated the adoption of technology in healthcare. By leveraging these advancements, organizations can streamline compliance processes and improve efficiency.
“COVID finally put us in the 21st century with technology and forced us to become more technology-enabled,” said Duva, who has worked in healthcare technology for a quarter-century. “Now we have to leverage that technology for the greater good.”
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Conclusion
Addressing healthcare compliance challenges requires a comprehensive and proactive approach. Organizations can more effectively navigate the complexities of Medicare and Medicaid regulations by implementing a centralized compliance solution, leveraging AI and machine learning, and adopting a Compliance as a Service model.
To stay on top of the latest developments in the future of healthcare compliance, visit UST Evolve and UST Healthcare Life Sciences.