This Q&A with compliance expert, Lisa Herota, RHIA, CHC, CHIAP, CHPS, CCS covers best practices for a data-savvy compliance leader. Learn about realistic compliance metrics and how to share them effectively. Read more about Lisa’s background and experience at the end of this blog.
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It’s the nature of our mission to stay on top of what’s happening in the world of healthcare compliance. And right now, that focus couldn’t be more important.
These are unusual times, and Compliance is feeling the impact. The Medicare Fiscal Year 2026 Final Rules were expected to be late but came through on time. However, hospitals must still rush to analyze and respond with action plans in short order. CMS transmittals are also likely impacted by the government shutdown (more on that later).
That leaves many hospital compliance teams unprepared and under-resourced to cope with fast-coming changes. The price of noncompliance, even under extenuating circumstances, is reimbursement risk.
The CMS guidance for healthcare comes with its own deadlines attached, and every year there are two important and separate timelines for fiscal year and calendar year Final Rules.
In healthcare, fiscal year guidance typically has an October 1 effective date, and that Final Rule usually drops in August. This year, YouCompli analysts got through the fiscal year Final Rules incredibly quickly, because CMS cut a lot of the material in the preamble, and that allowed more efficient review and analysis.
As every seasoned compliance professional knows all too well, CMS puts out a handful of big, omnibus rules for different areas of health care on an annual basis. This time of the year brings us the final rules affecting outpatient costs and billing. These areas usually get addressed during the calendar year, and these calendar year communications started dropping this year on November 5. That gives an effective date of January 1 of the next year.
It’s important to get these annual changes synthesized and implemented in a health care organization because they cover the entire year. Even when Rules drop at the usual time (and not during a government shutdown), the short time frame to the established effective date still puts pressure on providers to analyze and develop a compliance action plan. That’s where having a partner like YouCompli already breaking down these rules and translating them into actionable business requirements is essential.
On top of concerns about Final Rules delays, CMS transmittals ceased to come out on September 30. Transmittals are typically issued on a running basis as they come up. In a given month, you can have anywhere from 15 to 150 transmittals come out.
A CMS transmittal is not the same as a Final Rule. They are two distinct types of guidance documents from the CMS. Transmittals are official documents to communicate new or changed policies, procedures, claims and other operational guidance to Medicare administrative contractors (MAC), regional offices, and healthcare providers. The communications update specific CMS program manuals, instructions, and other documentation to ensure consistent implementation of Medicare rules.
Another job of a transmittal is to direct the MACs on what to do in processing claims. These third-party contractors are hired by CMS to administer claims, and they can get backlogged on their instructions and claims processing when transmittals run late.
Any claims processing delays impact providers, so it’s important to keep an eye on when these transmittal communications come out, especially if it drags out for weeks. If MACs struggle with claims processing because they can’t keep up with the updates, providers lose money.
Whether it be through time-related loss, because then they have to reissue claims with fixes and things of that nature, delays directly impact revenues. That’s not good at a time when health systems are already under the gun.
If you’re a YouCompli customer, you wouldn’t have to scramble to prepare for last-minute changes, because we would handle it.
If communications are ever delayed, creating a time crunch, let us act as your analysist team, grabbing communications as soon as they come out, and breaking it down for you. We capture the necessary data and deliver it, along with easily understandable business requirements.
You’ll know what you need to do to comply, so when the next Final Rule or transmittal hits your inbox, you’re ready to run with updating procedures, training and other requirements.
We suggest getting on board with us now, so when that time comes, you’re not struggling with these risks and delays.
About the Author
Nate Ward, J.D. is the Manager of Compliance and Content Development at YouCompli Software. He comes from a deep background in healthcare compliance and the legal field. Nate leads a team of experts who read regulations, analyze how they apply, and recommend action plans for healthcare compliance.
Compliance professionals sometimes feel undervalued in comparison to other functions in their organization. They think leaders and colleagues don’t really understand what they do.
These resources will help. Packed with ideas, tips and recommendations, these pieces were written by professionals with many years of compliance experience.
You can quickly skim for articles that relate to your needs and interests. Bookmark this page as a reference for future questions or projects.
In this blog, experts offer the real scoop on audit readiness in healthcare. Learn the unfiltered truth about compliance audits and what audit etiquette means. Get essential tips on preparing for audits, the role of healthcare compliance auditors, and what to do (and what not do) during an audit.
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A conflict of interest (COI) in healthcare occurs when a person or organization involved in medical decision-making, such as a doctor, researcher or healthcare administrator, has a secondary interest (financial, professional or personal) that could compromise or influence their objectivity and clinical judgment.
This secondary interest has the potential to affect decisions about diagnosis, treatment, or research in a way that’s not aligned with the best interests of the patient or public health.
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In this expert interview, Amy shares insight surrounding compliance management software (like YouCompli) and examples of what it takes for organizations to be successful.
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In Q3, the exclusion screening software glitched. It missed a monthly sync. Then a second. By the third missed month, the compliance officer dismissed it as “a minor lag,” promising the HR department everything would be rerun soon.
Unfortunately, even a seemingly small glitch can have major consequences for healthcare compliance.”
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Traditionally, many healthcare compliance programs have left the work of patient safety and quality to other departments. However, according to the Health and Human Services (HHS) Office of Inspector General (OIG), “Entities should incorporate patient safety/quality oversight into their compliance programs.”
OIG’s recent emphasis on patient safety and quality is not necessarily a call for compliance programs to take over these efforts. Rather, it’s a reminder that a compliance program should be designed to address the significant risks health care organizations face, which includes patient safety and quality of care.
How can your compliance program answer the OIG’s call and include patient safety and quality in your oversight efforts? This blog explores four practices to integrate safety/quality concerns into compliance practices.
1. Build a Strong Compliance Committee
2. Provide Safe Reporting for Safety/Quality Concerns
3. Get Your Governing Board Involved with Quality of Care
4. Nurture Relationships with Quality and Safety Leaders
Most mature compliance programs have a compliance committee in some form or fashion. To build stronger safety and quality representation, include individuals responsible for quality assurance and patient safety as members of the committee.
A strong compliance committee should ensure that appropriate auditing and monitoring of patient safety and quality take place on a regular basis. The OIG goes as far as suggesting that “Compliance committees of entities directly furnishing patient care, particularly entities such as hospitals, long-term care facilities, and other entities providing residential care, should also assess staffing for nursing, therapy, and other clinical services to ensure that the entity has the appropriate quantity, quality, and composition of care providers.”
Compliance programs establish lines of communication for reporting concerns, and anyone aware of patient safety or quality concerns must know how to report such incidents or issues. They must also have confidence they won’t face retaliation.
Awareness of incidents involving safety or quality is often the first step in developing a correction plan, so it’s essential that those who report know how their information is protected.
Steps have been taken at the federal level to encourage reporting and analysis of medical errors. The Patient Safety Act and Rule provide federal privilege and confidentiality protections for patient safety information called the Patient Safety Work Product (PSWP). PSWP includes data, reports, records, analyses and written or oral statements related to patient safety events.
More about the types of protections at the federal level can be found here: https://www.hhs.gov/hipaa/for-professionals/patient-safety/index.html
Governing boards of healthcare entities have ultimate accountability for ensuring quality of care, and their involvement can also ultimately benefit compliance outcomes.
There are many resources available to educate your board on their responsibilities related to quality. These include:
Read and share these with board members to help them stay informed more easily.
Compliance departments aren’t expected to take over the detailed, day-to-day management of quality and patient safety programs. However, it’s essential that compliance leaders develop productive working relationships with leaders and in-house experts within the organization’s quality and patient safety programs.
One way to develop productive working relationships is to better understand what quality and safety leaders do. A good resource for learning more about the standards, goals and language often used by quality and safety leaders is the Institute for Healthcare Improvement or IHI (https://www.ihi.org/).
This organization offers both introductory, intermediate and advance learning opportunities for those who want to become better-versed in quality and patient safety topics. The IHI Open School (https://www.ihi.org/education/ihi-open-school) is a great place to start. And for those looking for more formal recognition, the IHI offers certifications, such as the Certified Professional in Patient Safety (CPPS)™.
The call for compliance programs to become more involved in an organization’s patient safety and quality efforts is getting louder from agencies such as the OIG. It’s also smart business practice.
In summary, this blog has covered four ways to begin the process:
With these practices in your toolkit, you’ll be on the path to a stronger, more effective compliance program.
And to help with overall regulatory analysis and operations, learn more about how YouCompli compliance software can support your mission. The tools include capabilities to easily map and track responsibilities across functions.
CJ Wolf, MD, M.Ed. is a healthcare compliance professional with over 22 years of experience in healthcare economics, revenue cycle, coding, billing, and healthcare compliance. He has worked for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System, an international medical device company and a healthcare compliance software start up. Currently, Dr. Wolf teaches and provides private healthcare compliance and coding consulting services as well as training.
Compliance professionals sometimes feel undervalued in comparison to other functions in their organization. They think leaders and colleagues don’t really understand what they do.
These resources will help. Packed with ideas, tips and recommendations, these pieces were written by professionals with many years of compliance experience.
You can quickly skim for articles that relate to your needs and interests. Bookmark this page as a reference for future questions or projects.
“Compliance in healthcare isn’t just about meeting regulatory requirements – it’s about protecting patients, maintaining trust, and ensuring operational efficiency. Too often, compliance is treated like a separate function and oftentimes a bit disconnected from department heads, operations and leadership.”
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“Healthcare compliance professionals face significant challenges when managing who is responsible for completing compliance activities. From identifying the right individuals to ensuring accountability and avoiding duplication, the process can be fraught with inefficiencies.”
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