Healthcare compliance: It’s the undercurrent that drives safe and effective medical care. It’s also an elaborate way to describe the process for following rules, regulations, and laws pertaining to healthcare practices. Compliant healthcare organizations strive to maintain smooth operations to keep patients safe and ensure optimal outcomes. Fortunately, there are a variety of healthcare compliance tools that remove some of the operational burden associated with implementing complex healthcare regulations.

These tools help healthcare organizations identify and mitigate risk so they can focus on staff well-being and providing high-quality patient care.

Why is there so much focus on compliance in the healthcare industry?

Unlike other industries also governed by compliance, the healthcare industry is different because the stakes are higher—much higher. If a doctor or nurse, for example, doesn’t follow proper protocols, they can end up injuring a patient or another staff member. What’s worse is that if the reporting mechanisms in place are insufficient, these and other incidents may go largely undetected or unaddressed. With little to no intervention, the risk is perpetuated unnecessarily over time.

In addition, healthcare is a fast-paced environment. Ensuring safety requires healthcare organizations to monitor and manage everyone who enters the facility, including patients, vendor representatives, and others. COVID-19—as well as increased privacy and security concerns and a variety of other factors—continues to amplify the need to track and manage visitor access.

Healthcare billing compliance is another topic that often gets a lot of well-deserved attention. Incorrect billing can lead to under- and overpayments, and it can also negatively affect the patient financial experience. All healthcare organizations need to mitigate costly denials, fines, and penalties due to noncompliant coding and billing.

Healthcare compliance plays a critical role in all of these things, and it’s also an essential part of delivering a memorable and positive patient experience.

What are some topics that pertain to healthcare compliance?

The list of healthcare industry rules and regulations is long—and many of the requirements are extraordinarily complex. The good news is that they all tend to fall into one of three broad categories. The other good news is that there are a variety of healthcare compliance tools to aid performance. Consider the following compliance categories:

  • Patient safety. These regulations are designed to improve the quality and safety of U.S. health care delivery.
  • Privacy of health information. These regulations are meant to protect a patient’s medical, personal, and financial details. Most notable is the Health Insurance Portability and Accountability Act (HIPAA) that governs the privacy and security safeguards that must be in place for health information storage, release, and exchange. HIPAA ensures that certain technical, physical, and administrative safeguards are implemented and maintained.
  • Billing practices. These healthcare industry rules and regulations describe how and in what circumstances healthcare providers must bill payers and patients for services rendered.

How do organizations monitor compliance in healthcare?

Healthcare compliance is not the responsibility of one individual or even one department. An effective compliance program requires these three critical elements: People, processes, and technology.

People

To ensure healthcare compliance, organizations need a multidisciplinary compliance committee. This committee, which meets at least quarterly, typically includes representation from the C-suite, revenue cycle management, case management, and health information management. The HHS Office of Inspector General also recommends that these committees include clinical experts to provide frontline experience and perspectives.

Processes

Healthcare compliance requires written policies and procedures to which staff are held accountable. They key to consistency? Policies, procedures, and schedules detailed in a compliance handbook or other official document. In addition to policies, healthcare compliance also requires regular risk assessment and audits. This includes internal audits to ensure identify new areas at risk for denial and to ensure the effectiveness of corrective actions and education stemming from previous audits. In other words, have people learned from their mistakes, and are they improving

It also includes external audits by a third-party auditor. For example, an external auditor can review a sample of claims to identify high-risk areas, workflow inefficiencies, and areas of opportunity. This external review is critical for obtaining an objective performance evaluation. Remember: To truly reduce compliance risk, healthcare organizations must share audit findings with providers and other staff members. If people don’t know what they’re doing wrong, they can’t fix the problem(s), and thus the cycle of compliance risk continues.

Technology

Finally, healthcare organizations need technology to streamline risk identification and mitigation. Healthcare compliance is complicated, and it frequently evolves as rules and regulations change. Healthcare compliance tools help providers adapt to these changes more nimbly and without placing additional burden on physicians and staff.

What tools help organizations maintain healthcare compliance?

Healthcare compliance tools come in a variety of forms, and for the purposes of this article, we’ll discuss six of them:

Tool 1: Credentialing/privileging/peer review software

What it does: It manages the provider data lifecycle—verification, credentialing, payer enrollment, privileging, peer review, quality improvement, and risk management. The result? Faster turnaround times, tightened security, and improved workflows.

How it helps: It eliminates or reduces manual steps and reliance on paper processes, enabling staff to focus on higher, “value-added” responsibilities.

Tool 2: Incident management software

What it does: It captures (near) incidents, provides analytics, manages workflows, and monitors improvements.

How it helps: It encourages incident reporting to improve data collection and data analysis, as well as to promote a transparent and blame-free reporting environment. It also helps make staff more aware of conscious and unconscious behaviors that affect safety.

Tool 3: Vendor credentialing management software

What it does: It ensures that all vendors meet your organization’s custom requirements before being credentialed. It also provides dashboards that make it easy to track who is onsite (or who has appropriate virtual access) in real time.

How it helps: Vendor credentialing software controls access so healthcare organizations don’t run afoul of CMS, other regulations, and/or lose funding.

Tool 4: Visitor management software

What it does: It controls access to your healthcare organization through fast yet secure check-ins as well as visitor limits and requirements based on your facility’s unique needs.

How it helps: It enables healthcare organizations to track and manage visitor access and easily prepare for emergency situations.

Tool 5: HIPAA compliance software

What it does: It guides covered entities through their compliance efforts to ensure that they meet all provisions of the HIPAA Privacy, Security, Breach Notification, and Omnibus Rules. This includes helping them complete a HIPAA risk assessment process to identify, track, and remediate risks, as well as to comply with various other elements of HIPAA.

How it helps: It proves that a covered entity has made a good faith effort to comply with HIPAA by maintaining full documentation of all compliance activities.

Tool 6: Billing compliance software

What it does: Billing compliance software comes in a variety of forms. For example, claims scrubbers review claims prior to submission to ensure they meet all requirements dictated by Medicare, Medicaid, National Correct Coding Initiative Edits, and other standard coding rules. Billing compliance software may also help healthcare organizations track and trend denials by code, reason, payer, and provider. There are also solutions that rely on artificial intelligence to comb through medical record documentation to ensure compliant billing. For example, computer-assisted coding helps medical coders identify and validate compliant codes for billing. Computer-assisted physician documentation helps physicians document to the highest degree of specificity so coders can assign accurate medical codes.

How it helps: It enables healthcare organizations to take a proactive rather than reactive approach to denial management.

Track and manage compliance issues

Healthcare compliance is a complex and constantly evolving target. By combining people, processes, and healthcare compliance tools and technology, hospitals and health systems set themselves up to successfully navigate current and future challenges.

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