New compliance professionals benefit from a variety of resources to ramp up their knowledge and value. If you’re new to the healthcare compliance field (or know someone who is), save and share this article 

Getting Started for Early-Career Compliance Professionals 

The 20+ foundational resources that follow were curated from the YouCompli resource library. This set is tailored specifically for early-career compliance professionals. Start reading for ideas to build your: 

• Leadership skills 
• Operational credibility 
• Cross-departmental influence 

Read Expert-Sourced Content Designed for Professional Development 

Written for (and sometimes directly by) healthcare compliance executives, the information is practical and easy to understand. 

The articles focus on a variety of important topics: 

• Communication and Professional Growth for New Leaders 
• Operational and Audit Fundamentals for Building Compliance Expertise 
• Technology and Strategic Planning for Regulatory Change Management 
• Compliance Program Building and Oversight 
• Video Hub: Expert Guidance for Healthcare Compliance Professionals 
• Downloadable Tip Sheets for Quick Ideas and Actions 
   

Pick where you need help most today and dive in. (A few resources fall into multiple categories, so you get double the return when you read them.) 

Communication and Professional Growth for New Leaders 

From soft skills to dollar signs, these articles cover areas that sometimes get neglected in more formal compliance leader training. These expert resources cover aspects of compliance communications you might not find anywhere else. Learn about the persuasive communication skills that are the secret superpowers behind strong compliance leaders.  

Aggressive vs Assertive Communication: What New Healthcare Compliance Officers Need to Know  

Get advice tailored for new leaders on building authority and articulating compliance risks without creating unnecessary friction. New compliance executive can learn how to speak with authority and assertiveness without damaging cross-departmental relationships.  

This article covers:  

• Key differences between two common communication styles  
• How assertive communication benefits the compliance program  
• Strategies to help you master this skillset 

Integrate Self-Awareness into Healthcare Compliance Programs: 18 Tips  

Being aware of how we do our own work is paramount for an effective compliance program and incorporating self-awareness into your healthcare compliance program can enhance its effectiveness. For example, it improves your ability to empathize with the challenges operational leaders face when adjusting a process to meet a regulatory requirement. To help build awareness, explore these 18 actionable tips for compliance officers. 

Financial Literacy: The “Superpower” Every Modern Compliance Leader Needs  

For effective healthcare compliance leaders, financial literacy isn’t optional. Compliance risk often hides in the fine print of financial data, making literacy a prerequisite for effective oversight.  Explains key financial concepts so business newcomers can align compliance goals with executives’ organizational priorities.  

By confidently speaking the language of finance with terms like liquidity, capital planning and debt financing, compliance officers move beyond being seen as a “cost center” and the “Department of No.”  Instead, compliance can become a guardian of the organization’s financial sustainability, ensuring that compliance is integrated into every high-level discussion, from annual budgeting to long-term strategic growth.   

Operational and Audit Fundamentals for Building Compliance Expertise 

Business operations are essential partners in a good compliance program, and audits are foundational to healthcare compliance in those areas. These resources drill down into both, explaining how to reduce friction and frustration through proactive partnerships and education.  

Audit Readiness? How about Audit Etiquette?  

In this blog, experts offer the real scoop on audit readiness in healthcare. It outlines crucial operational protocols and relationship dynamics for leading teams through smooth, defensible audits. Learn the unfiltered truth about compliance audits and what audit etiquette means. Get essential tips on: 

• Preparing for audits 
• Role of healthcare compliance auditors 
• What to do (and what not do) during an audit 
• What does audit readiness mean? 

Healthcare Quality Leadership: How to Be an Operational Partner, Not a Roadblock  

In every organization, there’s a moment where the quality department becomes either the trusted operational partner or the operational roadblock. The difference between the two comes from how you communicate, assign responsibility and how you follow through. This blog explains how to adopt the OG style for more effective quality programs in healthcare, with “Three Ways to Partner like a Pro.” Direct the strategies that shift compliance from a gatekeeper to a strategic business enabler. 

Three Tips for Strong Compliance Education Practices  

Compliance orientation educates new staff members about company policies, procedures, and various regulations that govern their specific roles. Ongoing compliance training ensures that as regulations evolve, all employees are appropriately educated on implications and requirements. With its emphasis on risk management, compliance training protects both employees and organizations from legal and ethical pitfalls.  

A good understanding of compliance helps employees safeguard the company against lawsuits and reputational damage. Get core principles and three tips for clear, memorable staff training programs that drive actual behavioral change. Two experts – one in education and one in compliance – share advice and analogies to improve your compliance education practices.    

Technology and Strategic Planning for Regulatory Change Management 

Technology and strategy have a lot in common. We expect both to be versatile and responsive, while at the same time, they have to hold up and carry the organization over the long term. These selections explore ideas that will help novice leaders leverage technology to drive strategy and value.  

What to Look for in Regulatory Change Management Software for Healthcare Compliance 

The ROI of tools like the YouCompli Analytics Dashboard comes from actionable, on-demand information to reduce the risk of noncompliance, fines, and reputational damage. Further value comes from efficient, centralized documentation, dashboard details and insights into completed work. Get a practical checklist to help new leaders evaluate software capabilities for tool selection. Learn six non-negotiables for regulatory change management software and processes. 

AI Guide for Healthcare Compliance Leaders  

From Manual to Scalable: How to Manage Healthcare Compliance Risk 

Despite recognizing it as a top risk year after year, many organizations still manage regulatory change as a monitoring activity. Updates are tracked. Summaries are circulated.  But when change actually occurs, the organization is left to work out (often manually and inconsistently) what the change means and what to do next.  

From a systems-thinking perspective, this is a structural failure, not an execution problem.  In this piece, Lisa Estrada explores systems-thinking strategies to move beyond manual processes and build a scalable regulatory compliance process.  

Compliance Program Building and Oversight 

During your compliance career, you may have opportunities to build a program or at least manage one. Using the metrics and collaboration-building practices covered in these resources will set you on the path. 

5 Strategies for Compliance Accountability Across the Organization  

While supporting operational teams in finding compliant solutions is part of your role, becoming the de facto fixer of what constitutes “operationally friendly” is beyond your scope. That piece must be owned by operations.  The challenge becomes how to get operational leaders to take ownership to resolve their own compliance challenges. 

These five strategies will help you encourage your operational leaders to take responsibility for their particular compliance issues, while preserving your role as a trusted advisor. Respected compliance professional Jay Anstine outlines methods for instilling shared ownership of compliance requirements across clinical and administrative business units.  

Beyond the Penalty: What Metrics Should Healthcare Compliance Officers Track? 

How Slowing Down Makes for a More Productive Compliance Program  

As regulations change or investigations are needed, we often get pushed to work faster, meet tighter deadlines, and juggle multiple tasks simultaneously.  

While this approach might seem efficient on the surface, it often leads to serious downsides: 

• Burnout 
• Decreased productivity 
• Decline in the quality of work  

This interesting piece focuses on transitioning from reactive firefighting to building deliberate, repeatable compliance processes. You’ll get five solid tips to help you and your compliance team slow things down in a good way. 

Video Hub: Expert Guidance for Healthcare Compliance Professionals 

While we can’t go into all of them here, the YouCompli video library is packed with useful visual learning materials.  Explore the full catalog, featuring expert interviews and practical strategies. 

Real Conversations. Practical Compliance Insights. 

Where do you need ideas and advice? 

• Compliance Leadership & Mindset 
• Influence, Trust & Seat at the Table 
• Operationalizing Compliance  
• Efficiency, Clarity & Saving Time 
• Customer Perspectives & Real‑World Experience 

Hear directly from compliance leaders who understand the realities of the work. These short videos share honest perspectives on simplifying regulatory requirements, building trust with the business, and turning compliance into a strategic advantage. 

Downloadable Tip Sheets for Quick Ideas and Actions 

For the compliance leader on the go (isn’t that all of us?) the Tip Sheet Library offers quick, useful information. Explore the collection and start downloading tip sheets to start your own handy idea file. 

• Compliance Career Tips 
• Compliance Culture 
• Compliance & Business Strategy 
• Healthcare Quality 
• Industry Trends 
• Rev Cycle 
• Rules and Regulations 

Need More Specialized Support for Your Healthcare Compliance Program? 

Not only does YouCompli have educational resources to help compliance professionals, we also human resources who can help. If you’d like to speak to someone to answer any questions, just reach out. 

Download our Latest Whitepaper

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The post Resources to Accelerate New Healthcare Compliance Careers  first appeared on YouCompli.

Are you keeping up on your reading from the FY 2027 hospital inpatient prospective payment system (IPPS) Final Rule? True, it is close to 900 pages of Federal Register fine print, (https://www.govinfo.gov/content/pkg/FR-2026-08-04/pdf/2026-15833.pdf ) but there are four areas that prepared compliance professionals should be aware of. This blog takes you through the highlights of those important sections. 

What Does the Final Rule Mean for Your Organization? 

This release updates Medicare payment rates and policies for acute care and long-term care hospitals, with some starting as soon as January 1, 2027, so it’s definitely time to start paying close attention. 

1: Expansion of Comprehensive Care for Joint Replacement (CJR) Model 

The original CJR Model ran from April 2016 through December 2024 and according to CMS, it produced the needed results. The most recent evaluation of performance years six and seven (2021-2023) showed that the CJR Model produced an estimated $112.7 million in net savings while maintaining quality of care. 

Now, the CMS Innovation Center is expanding the model nationally, including in U.S. Territories, starting January 1, 2028. The expanded model, called CJR-X, will focus on improving care and reducing spending for Medicare beneficiaries undergoing lower extremity joint replacement (LEJR) procedures.  

CJR-X Mandatory Requirements for Some Acute Care Hospitals 

Participating hospitals will be held accountable for spending and quality of care during an inpatient stay or hospital outpatient procedure and for the 90 days following hospital discharge.  With some exceptions, the CJR–X Model will be mandatory for acute care hospitals paid under IPPS and Outpatient Prospective Payment Systems (OPPS).  

Multiple Modifications to CJR Model 

CJR–X also includes modifications to the CJR Model. The Final Rule confirms multiple policies for CJR-X.  These include: 

• January 1, 2028 start date 
• Acute care hospitals as participant and accountable entity 
• LEJR as the episode of care 
• Five quality measures and a composite quality score (CQS) to assess quality performance  
• Regional risk-adjusted target prices that include capped normalization and trend factors 
• Pricing-specific policies for certain hospitals, such as low-volume and safety net hospitals 
• Provider and beneficiary overlap permitted with most models 
• Allows participant hospitals to have financial arrangements 
• Waives certain Medicare program requirements 
• Permits beneficiary-identifiable and regional aggregated data sharing 
• Options for Alternative Payment Model (APM) participation  

Though compliance professionals aren’t likely to be named the implementation lead of these efforts at their hospital, they should still be aware of how these changes will affect reimbursement, quality reporting and allowances for financial arrangements. 

To learn more now and in the future about the CJR-X Model, stay tuned at https://www.cms.gov/priorities/innovation/innovation-models/cjr-x 

2: Organ Acquisition Costs 

Compliance professionals working in or with organizations providing organ acquisition services need to be aware of these changes and ensure policies, procedures and any auditing activity is adjusted accordingly. 

• The Final Rule outlines payment policies for organ acquisition and reasonable cost, as well as reimbursement appeals for Independent Organ Procurement Organizations (IOPOs) and Histocompatibility Laboratories (HCLs).   
• The Final Rule solidifies the proposal to clarify and codify certain longstanding policies on allowable costs under Medicare’s reasonable cost principles for all provider types, including public education for organ procurement organizations.  
• Additionally, it finalizes the proposal to clarify and codify Medicare’s longstanding policies for allocating overhead costs across all provider types.  
• Lastly, the final rule codifies the CMS administrator’s discretionary review of reimbursement appeals for IOPOs and HCLs.  

As HHS OIG states in their General Program Compliance Guidance, “One of the best ways to identify fraud and abuse risks is to follow the money.” Understanding the flow of money related to organ acquisition is one of those areas to add to the list for “following the money.” 

3. Quality, Quality, Quality. 

Quality of care is another area that the HHS OIG has been shining a light on for compliance professionals in recent years. Though it’s unlikely compliance professionals will take over quality of care programs in hospitals, OIG expects tight partnerships. Also expected is a general understanding by compliance departments of the work that hospitals’ quality of care teams perform. 

Specifically, OIG said, “Entities should incorporate quality and patient safety oversight into their compliance programs. Integrating quality and patient safety oversight into compliance processes can alert the entity of quality and patient safety concerns and enable the entity to mitigate risk of patient harm.” 

Quality Reporting and Compliance Impact 

The IPPS Final Rule has a lot to say about quality reporting. Although compliance professionals aren’t on the front line for some changes, they should ensure quality teams are aware and have a plan to address any potential impact.  

Quality-related highlights include: 

1. Adoption of three new measures: 

• Excess Days in Acute Care After Hospitalization for Diabetes measure beginning with the FY 2029 payment determination 
• Hospital Harm-Postoperative Venous Thromboembolism electronic clinical quality measure (eCQM) beginning with the FY 2030 payment determination 
• Advance Care Planning eCQM beginning with the FY 2030 payment determination 

2. Removal of three measures, beginning with FY 2030 payment determination:  

• Venous Thromboembolism Prophylaxis eCQM 
• Intensive Care Unit Venous Thromboembolism Prophylaxis eCQM 
• Discharged on Antithrombotic Therapy eCQM 

3. Modifications to three measures beginning with the FY 2028 payment determination. All are related to Excess Days in Acute Care after Hospitalization for: 

• Acute Myocardial Infarction 
• Heart Failure 
• Pneumonia 

4. Five modified mortality measures beginning with the FY 2028 payment determination.  Each relates to the Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate following: 

• Acute Myocardial Infarction Hospitalization  
• Heart Failure Hospitalization 
• Pneumonia Hospitalization  
• Chronic Obstructive Pulmonary Disease Hospitalization  
• Coronary Artery Bypass Graft Surgery  

4: Promoting Interoperability of Certified Electronic Health Record Technology 

The Medicare Promoting Interoperability Program encourages eligible hospitals and critical access hospitals to adopt, implement, upgrade and demonstrate meaningful use of certified electronic health record technology (CEHRT). 

In this Final Rule, CMS confirmed policies to: 

• Remove and revise certain criteria to align with proposals made by the Office of the National Coordinator for Health IT 
• Remove certain attestations  
• Delay removal of the following two measures: (i) Support Electronic Referral Loops by Sending Health Information and (ii) Support Electronic Referral Loops by Receiving and Reconciling Health Information  
• Modify the Electronic Prior Authorization measure as an optional bonus measure for the EHR reporting period in CY 2027 and mandatory beginning with the EHR reporting period in CY 2028 
• Add the Unique Device Identifiers for Implantable Medical Devices measure  
• Adopt two new eCQMs beginning with the FY 2030 payment determination in alignment with the Hospital Inpatient Quality Reporting Program 
• Remove three eCQMs beginning with the FY 2030 payment determination in alignment with the Hospital Inpatient Quality Reporting Program  

Build Business Knowledge to Anticipate Non-Compliance Risks 

Most compliance professionals are unlikely to be the assigned project lead on any of these announcements within their individual hospitals. But good compliance professionals need to understand their organization’s business lines and operations to anticipate where non-compliance could most likely occur. 

For those working with or for hospitals, the Hospital IPPS Final Rule is always a good place to review upcoming changes to hospital reimbursement, government policies and data reporting requirements.  

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.   

Stay Informed on Medical Necessity and More 

Read other blogs by Dr. CJ Wolf on YouCompli to stay current on information compliance leaders need. He covers these and other topics:  

• Regulatory and Enforcement Updates: Breaks down OIG Work Plan priorities, CMS policy updates, and healthcare regulatory changes. 
• Compliance Auditing and Risk: Offers practical advice on risk assessments, internal auditing, and building effective compliance programs. 
• Billing and Documentation Integrity: Examines compliance strategy related to coding integrity, medical necessity, and operational oversight. 

Here are a couple of articles to get you started. 

Don’t Let Pain Injections Cause Regulatory Compliance Pain 

The regulatory compliance landscape around SI joint injections is dynamic and significant. It’s worth paying attention to those devilish details.   

Four Areas of Noncompliance in SI Joint Injection Procedures  

Below are four categories of noncompliance and indications of unmet requirements: How SI Joint Injections Are Covered 

Medical Necessity: A Guide for Healthcare Compliance Leaders 

Ensuring medical necessity for services or supplies is a safeguard against unnecessary or duplicative services that increase the risk of patient harm or medical errors. That’s reason enough for this to be an important topic for compliance leaders.  

This piece explains the medical necessity compliance risk in general, while subsequent articles highlight specific examples of enforcement actions experienced by medical providers such as hospitals and health systems.

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The post Four Things to Know About the FY 2027 IPPS Final Rule  first appeared on YouCompli.

About the Medical Necessity Series 

This is the third in our series of articles on medical necessity. In the first, we described the compliance risks associated with submission of claims for medically unnecessary services.   

In the second, we highlighted a case where an organization of long-term care hospitals were alleged to have violated the Federal False Claims Act (FCA) for holding patients in the hospital longer than medically necessary to increase reimbursement from Medicare. 

In this next article, we spotlight another recent example of a healthcare provider entity agreeing to pay a six-figure sum to resolve allegations of submission of claims for medically unnecessary services¹.  This time, the providers consisted of three affiliated skilled nursing facilities (SNF) that were alleged to have submitted claims for medically unnecessary rehabilitation services.   

False Claims Act Metrics Make Significance Clear 

The Department of Justice has reported that False Claims Act settlements and judgments reached $6.8 billion in Fiscal Year 2025. Over $5.7 billion of that total was derived entirely from the healthcare sector. Most of these healthcare recoveries stem from whistleblower lawsuits targeting corporate billing schemes, upcoding, and medically unnecessary services. 

Case Involves SNF Reimbursement Dispute Over Therapy Services 

For the period in question, skilled nursing facilities (SNFs) were reimbursed for therapy services based on a patient’s resource utilization group (RUG). The RUG was determined by the amount of services the patient received, such as: 

•  Physical therapy 
• Occupational therapy  
• Speech pathology services 

In short, the more services provided, the higher the reimbursement.  However, as discussed in our two prior articles, if the services don’t meet medical necessity requirements, they should not have been performed or billed in the first place. 

Whistleblower Lawsuit Triggers Investigation 

As is frequently the case, these allegations were first brought forth through a qui tam, or whistleblower, lawsuit. The whistleblower, or relator, claimed the defendants implemented a five-pronged scheme to fraudulently bill for unnecessary “Ultra High Rehab,” (the most intensive therapy provided by SNFs) and to keep patients in Ultra High Rehab for longer than necessary. 

The five prongs of the alleged scheme were: 

1. Pressure to perform excessive, unnecessary services: The organization’s leadership exerted pressure on therapy staff to administer excessive Ultra High Rehab and to do so for longer than necessary.   

This pressure was exerted not only by administrators who oversaw SNF operations, but also by regional directors of operations who managed the facility administrators. Such pressure was also exerted by directors of rehab (DOR) who managed therapists at each facility, and regional managers who directly managed the DORs.  

In other words, management, from top to bottom, spoke to therapists and staff in one voice: increase Ultra High Rehab, regardless of patient need. 

2. Financial vs. medical reasons to provide care:  Instead of letting therapists determine the appropriate level of therapy needed based on their professional evaluation, leadership insisted that each patient’s level of therapy be at least in part determined by whether the patient qualified for lucrative Medicare Part A benefits. 

3. Care for functional patients: The organizations pressured therapists to continue providing therapy to patients who were fully functional and in no way required intensive therapy. A scheme called “Bridge to Success” was employed which mandated an additional week of Ultra High Rehab be tacked on even after patients were ready for discharge. 

4. Too sick for care: The organizations pressured therapists to provide therapy to patients who were too sick to benefit from therapy and even to patients who were actually harmed by it.  

Since therapy minutes were dictated by management and not assigned based on the professional opinion of evaluating therapists, patients ended up receiving more therapy than they could tolerate, including instances where therapy was forced on patients about to pass away. 

5. Maximizing minutes: The focus on maximizing therapy minutes to hit therapy goals also resulted in leadership encouraging an array of fraudulent billing practices. 

This included: 

• Billing non-therapeutic minutes as therapy  
• Allowing therapists to bill for therapy without actually providing it 
• Encouraging therapists to bill evaluation sessions as therapy. 

Widespread Occurrences Involve $14.6+ Billion in Alleged Intended Losses 

Federal enforcement actions emphasize the commonality of these practices. The 2025 National Health Care Fraud Takedown alone resulted in criminal charges against 324 defendants nationwide, involving over $14.6 billion in alleged intended losses tied to fraudulent billing and medical necessity abuses. 

The most compelling argument for compliance leaders is that medical necessity fraud carries dual liability: 

• Financial Risk: Organizations face mandatory treble damages (three times the government’s actual loss) plus steep statutory penalties for every individual false claim submitted. 
• Human Risk: Unlike administrative billing errors, medical necessity fraud directly compromises patient care. Overutilization exposes vulnerable patients to unnecessary, exhausting or potentially harmful procedures simply to satisfy corporate revenue targets. 

Three Takeaways from Medical Necessity Cases 

Much can be learned from the themes of these allegations, even if your organization isn’t an SNF or doesn’t provide therapy services. Medical necessity requirements are common across most healthcare organizations. 

Key lessons from this case include: 

1. Decisions about billing for medical care provided need to be based on clinical and regulatory requirements, especially coverage requirements from Medicare and Medicaid, for example.   Such requirements often include statutes about: 

• Medicare coverage 
• Medicare manuals 
• National Coverage Determinations  
• Regional Medicare Administrative Contractors’ Local Coverage Determinations (LCD)  

2. Regular, focused compliance coding and billing audits may identify aberrant practices. This is especially true for services whose corresponding medical documentation doesn’t support compliance with coding or billing rules.   
    
   For example, Medicare reimbursement rules state that routine, non-skilled services aren’t separately reimbursable. In this case, it was alleged that one therapy assistant was coached to include in therapy minutes the time it took him to arrive at a patient’s room starting with the moment he left the therapy department. 
    

3. Use data analytics to identify outliers. Most whistleblower cases alleging medically unnecessary services are brought by an individual with knowledge from inside the organization. Many times, the individual is a physician, nurse or other clinician with medical expertise.   
    
   This case was different. It was filed by a private analytics firm using publicly available data. Though rare, these cases do exist. If a private firm using public data could find the alleged aberrations, one would hope the organization’s own compliance professionals would be able to find similar aberrations if given the resources to look.  Additionally, the government is using data analytics to identify cases they want to pursue as well. 

Apply These Takeaways to Your Own Regulatory Compliance Program 

False Claims Act allegations alleging a lack of medical necessity can take many forms. The kind of service or type of provider may also vary, but these key themes appear in many cases. The astute compliance professional will learn from them and apply the principles to the operations and services provided at their own healthcare organization. 

The claims resolved by the settlement are allegations only, and there has been no determination of liability. 

The post Lessons from the Frontlines: A Case Study in Medical Necessity Enforcement  first appeared on YouCompli.

Description: Elevate your audit strategy. Access 7 top educational resources designed to help healthcare compliance leaders navigate complex commercial and federal reviews.  

Trying to get a better handle on audit readiness? Good move. To save you some time, we’ve curated this audit-related content specifically for healthcare compliance professionals. The overview compilation gives you a quick look at the useful advice in each resource, so you can dive right into where you need help the most.  

If you haven’t thought about audit readiness lately, it’s probably time to put some focus on it. However, we know compliance life moves fast, and you can’t always get to some of the important things proactively. 

Compliance leaders get exhausted by resource scarcity, manual tracking fatigue, and escalating payer audits. According to the Barnes & Thornburg Compliance Outlook Report, 56% of healthcare compliance and risk leaders anticipate even greater regulatory challenges ahead, with over half struggling to secure the resources needed to keep up.  

So yeah, a proactive audit strategy could be a good idea. 

Healthcare Compliance Audits: 7 Essential Resources for Leaders 

Given that, it’s not surprising that continuous readiness is becoming the new standard for healthcare compliance leaders when it comes to audits. 

This collection is about shifting the conversation from “surviving the next audit” to “building a defensible, tech-forward compliance data engine”. 

These resources will quickly get you headed down a good path, with their abundant advice and useful tips from compliance professionals for compliance professionals. Many of them come with their own downloadable tip sheets. 

Think of the collection as the start of your “audit preparedness playbook.” 

Resource 1 – With Compliance Audits, The Best Defense is a Good Offense  

Is your organization defensible against a compliance audit? Do you have a game plan in place to avoid penalties and other losses? 

Traditional point-in-time random sampling simply fails to catch systemic gaps that audits can reveal. 

How this resource helps: 

With this blog, learn how to prepare your compliance program for the win. Using sports training analogies, the authors present a better way to handle ongoing inspections and audits in healthcare systems. 

The fast-break transition offense the authors suggest is inspired by the 1990 UNLV Running Rebels basketball team. Get their unique advice on how to go offense following a regulatory compliance audit or inspection, so you’re well-prepared for the next one. 

It takes practice. By reinforcing these principles and working on conditioning and decision making, teams can create more scoring opportunities. Just as a prepared team can force the defense into difficult situations, a well-prepared compliance team can “force” the auditor into zero-findings and more quality inspections.   

Resource 2 – Audit Readiness? How about Audit Etiquette?  

When a regulator shows up, what’s the first thing your team scrambles to find? 

• Is it evidence of task completion?  
• Maybe a list of applicable regs or updated policies?  
• How about proof of communication to stakeholders? 

In addition to documentation, how your team behaves during an audit also affects the outcome. 

How this resource helps: 

Learn the unfiltered truth about compliance audits and “audit etiquette” — the proper behavior for responding to an audit. 

Get expert tips on: 

• What audit readiness means 
• The role of healthcare compliance auditors 
• What to do (and what not do) during an audit 
• Audit etiquette best practices 

Perception is reality. If you look like you know what you’re doing, respond promptly, and treat the auditors with respect, you can generally minimize any damage. With the advice in this blog, you won’t just look ready; you’ll be ready – and calm.  

Follow these practices and display confident compliance audit behavior. 

Resource 3 – Healthcare Audit? Stay Ready. Don’t Get Ready.  

Compliance audit in Quality? Many quality teams think they’re ready, until they aren’t.  

In healthcare quality departments, audit readiness is no different than in any other area. Follow a defined process, then optimize as necessary so it works for your organization and patients.  

It’s not hard, but people still panic because an auditor can shut them down. 

However, if you have a proactive process in place to minimize the damage, you don’t have to worry.  

How this resource helps: 

This resource shares the pre-audit steps you need for proactive compliance readiness in Quality. It’s jammed with advice from the first word to the last. 

• During the Compliance Audit 
• Post-Audit Follow-Up Practices 
• Be Proactive: Prepare for Your Next Compliance Audit  

Resource 4 – How to Use TPE Plans for Compliance Auditing and Monitoring  

When doing periodic risk assessments, compliance professionals often use the OIG Work Plan or DOJ enforcement actions to determine how to deploy time and resources on auditing and monitoring. 

Another helpful tool is the list of services that Medicare Administrative Contractors (MACs) include in their Target, Probe and Educate (TPE) plans.  According to CMS, the goal of TPE is to accelerate improvement and let MACs work with providers to correct specific errors. 

How this resource helps: 

As this expert-written piece explains, TPE information can be a good resource for compliance leaders when designing proactive audit plans.  

This blog looks at how TPE plans are applied to specific areas of non-compliance that MACs observe. Use them to create your own checklists for cleaner compliance audits and proactive monitoring.  

Resource 5 – Six key steps to reduce the impact of telehealth audits 

Did you know telehealth is almost as old as the telephone itself? 

In 1879, just three years after Bell patented the telephone, an article in The Lancet first described the telehealth concept and its use.  

And a law that’s even older than the telephone still triggers telehealth audits today.  

The 1863 False Claims Act was enacted to keep profiteering contractors from defrauding the Union army. Today, it can trigger serious problems for modern telehealth practitioners.  

How this resource helps: 

Today we know the best way to cope with audits is to avoid the need for them in the first place. This article shares six proactive steps to take to reduce the impact of telehealth audits.  

It includes advice on how to: 

• Know what you’re up against.  
• Inventory your waivers.  
• Check your records.  
• Audit your process.  
• Fix what’s broken.  
• Rebill and repay.  

Patient demand for telehealth isn’t going away. Neither are the costs of noncompliance with telehealth regulations.  

By proactively partnering with colleagues in relevant departments, your compliance team can lead the efforts to identify and fix issues before they become major problems. That way, you can provide the telehealth services patients want in compliance with what the regulations demand. 

Resource 6 – 5 Payer Audit Errors Every Hospital Must Avoid 

From large hospitals to solo practitioners, at some point most providers will experience a commercial payer audit from CMS, OCR or some other agency. Their scrutiny reveals errors and violations, which in turn trigger hefty penalties. In fact, commercial payer audits have jumped 2.2 times over a single year, increasing the total sum at risk for hospital systems by 30%.  

Even more challenging, payers are moving heavily toward pre-payment audits. These can hold up payments and squeeze monthly cash flow.  

External payer audits don’t have to be such a nightmare.  

How this resource helps: 

The key to surviving an external audit with the least pain is to avoid the five payer audit errors outlined in this blog. 

1. Late responses 
2. Wrong documentation 
3. Billing the wrong codes 
4. No self-audit 
5. No legal help 

By staying prepared and vigilant, your next payer audit experience can be more streamlined and less stressful. 

Resource 7 – Audit Expectations and Challenges 

When it comes to providing best-in-class healthcare, stress comes with the territory. Unrelenting demands drain resources across the organization, including some not directly involved with patient care.  

One demand that turns daily routines upside down, and compounds stress levels is an audit. A compliance audit can be conducted internally by hospital committees or externally, often by government-approved contractors. 

Internal Audit – Seeks to determine provider’s financial and operational controls, and that related policies and procedures meet compliance and risk management needs. 

External Audits – Several federal agencies including CMS, OIG, OCR and others are the primary drivers of audits of regulations and compliance costs across hospitals. Responding to multiple external audits increases administrative costs, and funds could be bound up in lengthy appeals. 

How this resource helps: 

Study this overview to familiarize yourself with the basic workings and typical costs associated with audits. For example, external audits are conservatively estimated at $100 per hour, but the manual drain goes deeper:. Standard program reviews require 300 to 346 hours of direct manual labor per plan, taking skilled leaders away from higher-level risk mitigation. 

The Tech-Driven Path to a Proactive Audit Strategy 

You have plenty of insightful and helpful resources to review here. But as you look through them, keep this reality check in mind: 40% of compliance teams still rely on spreadsheets and text documents to track internal reviews. 

The future belongs to compliance leaders who lean into automated tools, allowing their teams to complete risk assessments far faster than manual methods and catch errors before federal or commercial auditors flag them. 

If you’re ready to leave the spreadsheets behind, or just have questions about setting up your proactive audit framework, we’re always here to talk. 

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The post Master Healthcare Compliance Audits: Learn from 7 Expert Resources  first appeared on YouCompli.

Compliance risks associated with medical necessity happen when providers fail to show clinical evidence that a service is essential for a patient’s health. This often leads to legal, financial and operational consequences. 

This article uses a specific example to explore the implications of medical necessity for healthcare systems. 

Recent False Claims Act Complaint Hinges on Medical Necessity  

Recently we wrote an introductory article discussing in general terms the compliance risks associated with medical necessity. That was first in a series on medical necessity. Now this article introduces a specific example.   

In this case, the U.S Department of Justice (DOJ) filed a False Claims Act complaint against a hospital group and three long-term care hospitals. They allege the False Claims Act was violated because some of the care provided (for which the hospital was reimbursed) wasn’t medically necessary. 

Three Ways Medical Necessity Impacts Performance 

Medical necessity remains a serious compliance risk for providers, including hospitals and health systems. It impacts these organizations in several significant ways: 

• Performance and Efficiency 
• Financial and Compliance Risk 
• Patient Outcomes and Quality 

1. Performance and Efficiency 

Administrative Burden: Research shows that “medical necessity” serves as a primary tool for allocating resources, but varying definitions across payers create administrative churn. Studies indicate that managing these requirements increases the revenue cycle workload, leading to delayed payments and reduced efficiency. 

Operational Streamlining: Conversely, some evidence suggests that when medical necessity is effectively operationalized (e.g., integrated into EHRs), it can increase the speed of diagnosis by eliminating redundant or non-essential tests.  

2. Financial and Compliance Risk 

Denial Management: A major area of study involves “medical necessity” as a driver of claim denials. Research by organizations like AAPC indicates that failure to validate medical necessity can lead to revenue loss, recoupments, and payer audits. 

Regulatory Exposure: Inadequate documentation of medical necessity is a leading cause of False Claims Act allegations, representing a high-stakes legal and compliance risk for health systems.  

3. Patient Outcomes and Quality 

Care Appropriateness: Studies suggest that medical necessity standards help align clinical care with evidence-based guidelines, which can improve patient safety by reducing exposure to unnecessary, potentially harmful procedures. 

Equity and Access: Research into determinants of health system performance warns that restrictive criteria can limit access to essential care for vulnerable populations if based on cost-containment instead of individual patient needs.  

Allege Longer Stays to Increase Medicare Reimbursement 

The example covered here reflects some of these negative impacts. In this False Claims case, the DOJ alleges that the hospitals held patients in the hospital longer than medically necessary in order to increase Medicare reimbursement.  

Long-term care hospitals (LTCHs) provide inpatient services for patients whose medically complex conditions require long hospital stays and programs of care. Medicare reimburses LTCHs based, in part, on a patient’s length of stay.   

By allegedly delaying discharge of certain patients, even when their course of treatment had been completed or when they could have been transferred to a lower level of care, the hospital received higher payments than they should have. 

The DOJ did not discover this issue on their own. The lawsuit was originally filed by a former employee of one of the hospitals through the qui tam or whistleblower provisions of the False Claims Act.  

How Internal Concerns Become Full-Blown Investigations 

Though allegations of medically unnecessary care may be a common reason such lawsuits are filed, understanding the details of a specific case is important.  

It can help compliance professionals see how concerns, potentially first reported internally, can develop into full blown investigations or additional complaints being filed with the court by the DOJ, as in this example. 

Manipulating Qualifying Patient Stays for Higher Reimbursement 

In the complaint, the DOJ alleges that the defendants illegally inflated their Medicare payments by holding patients who were ready for discharge until they reached a certain threshold date that, once reached, would trigger increased reimbursement.  

Certain Medicare patients who meet an average length of stay over the twenty-five days that LTCHs must maintain are referred to as a Qualifying Patient. The Government claimed the defendants also inappropriately held Qualifying Patients long enough to meet the 25-day average length of stay requirement to maintain their LTCH status and be paid at the higher LTCH rate.  

In the court document filed by the DOJ, it’s alleged that one executive told her employees, “No one is leaving early. We lose money.” Unfortunately, this wasn’t the only example of their alleged poorly handled medical necessity determinations. 

Ignored Alternatives Could Have Been Fraction of the Cost 

According to the complaint, many of these patients could have been discharged earlier and received care at home or in a nursing facility for a fraction of the cost to Medicare.   

The complaint also states that when employees raised concerns about the practices to one of its executives, the executive dismissed them, noting they would make money even if Medicare denied some medically unnecessary claims.  

Compliance Responsible for Appropriate Processes 

Compliance programs should ensure that appropriate processes exist to confirm the appropriate clinical criteria are met when it comes to admission and discharge actions.  According to the government, LTCHs specifically must have a documented process that: 

“screens patients prior to admission for appropriateness of admission to a long-term care hospital, validates within 48 hours of admission that patients meet admission criteria for long-term care hospitals, regularly evaluates patients throughout their stay for continuation of care in a long-term care hospital, and assesses the available discharge options when patients no longer meet such continued stay criteria.” 

The government states that in 2017, CMS observed that LTCHs appeared to be improperly holding patients beyond the key time threshold to obtain the full payment, which resulted in potentially improper delays in patient discharges other than solely for medical reasons.  

As a result, in fiscal year 2018, CMS revised the payment methodology to reduce LTCHs’ financial incentive to delay patient discharges until after the threshold. 

Example of Inappropriate Intent to Maximize Revenue 

The DOJ’s complaint contains statements that appear to imply they have emails or other documentation that show the intent to delay discharge. For example, an executive allegedly emailed a broad group of staff to praise them for getting “patients discharged on their correct discharge day to maximize our revenue.”   

Reportedly, the same executive also developed a bonus plan for a case manager in 2018 that required her to discharge 90 percent of patients on the “ideal discharge date” to receive a bonus. The ideal discharge date was a date calculated in a way (and reported on a dashboard) to lengthen the stay to meet higher reimbursement goals. 

Of course, the claims asserted in the complaint filed by the DOJ are allegations only.  However, most of the time the DOJ is not going to file a complaint if they do not believe they have or will obtain the evidence they need to either pursue the case further in court or lead to a mutually agreed upon financial settlement. 

Requirements for Medical Necessity Determinations 

Medical necessity determinations tend to be circumstance-specific. Auditing and monitoring for medical necessity will also typically require the involvement of a professional with clinical training or background.   

At times, it may be appropriate (if there are no conflicts of interest) to have a medical director from the organization be involved in such determinations. At other times, it may be a better idea to seek independent expertise from someone outside your organization. 

Learn from Examples of Medical Necessity Problems 

Watch for the next article in this series when we take another deep dive into an example of medical necessity in healthcare. In the meantime, browse these curated selections. 

Find More Advice and Ideas in These Related Articles 

• Introductory Article: Understanding Medical Necessity Compliance Risks The first post in this series, covering the foundational definitions and general compliance risks healthcare providers face today. 
• The False Claims Act: A Guide for Healthcare Leaders A deeper look into how inadequate documentation can trigger False Claims Act allegations and the resulting legal stakes for health systems. 
• Strategies for Reducing Claim Denials and Revenue Loss Practical insights into how medical necessity acts as a driver for claim denials and how to improve your revenue cycle workload. 
• Aligning Clinical Care with Evidence-Based Guidelines Learn how to leverage medical necessity standards to improve patient safety and ensure care appropriateness across your organization. 

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.   

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The post When Compliance Risk Is Driven by Medical Necessity Problems  first appeared on YouCompli.

It amazes us how many healthcare facilities don’t always store records appropriately. Check that. People don’t store records properly.  

Just this week, I was in a colleague’s office. Literally, it looked like Staples puked up aisle 3. I asked her what everything was, because you couldn’t make heads or tails of any of it. She explained that it was patient records that she didn’t know what to do with.  

I asked her, “Well, what does the process say to do?”  

“Process?” she said. Nice girl, means well, greener than a pepper tree.  

After helping her re-organize everything, I was motivated to put together some ideas to help others in her situation. Here are some record retention best practices in the event you have hoarded up some claptrap and now have to figure out what to do with it.  

What Records Do You Have? Archival or Data? 

First step, take an assessment of everything you have. Samples? Materials? Records?  

Archival storage should be for all original records, including source data and metadata, which are generated, recorded, calculated or transcribed at the time of an activity. This data allows full and complete reconstruction and evaluation of the activity.  

Data storage may be written, printed electronically, scanned image, photographic, or other form for later reference. Raw data obtained from measurement, testing, processing, direct observation or computer, and instrument printouts should be represented exactly as captured at its source without transformation, aggregation or calculation.  

Responsible Parties and Retention Periods 

All personnel should be responsible for handling, submitting or returning records to the archive in the same conditions in which they were found.  

Keep in mind that different items are governed by different regulations, so you need to check retention periods. The retention period begins when all work with samples or records is complete. Specified retention periods supersede any other retention requirements unless explicitly noted. 

Factors Influencing Retention Period Requirements 

• State and federal laws: State laws are the primary source for retention periods, which can range from three to over ten years. Federal laws, like those from CMS for Medicare, may also have specific requirements.  
• Patient age: Records for minors often require longer retention periods, usually extending past the age of majority.  
• Type of record: Different types of records can have different retention requirements. For instance, some states require longer retention for certain records like mammography images.  
• Legal and regulatory changes: Laws and regulations can change, so it’s important to stay updated on current requirements. 

Scope of Work in Healthcare Records Retention Process 

Generally, quality or project management takes the lead on records retention. The scope of work involves: 

• Archiving, filing, retaining, organizing and retrieving records 
• Maintaining security and integrity of records in archives if stored on-site 
• Collecting and cataloging records, including: 
• Assigning archival numbers 
• Preparing archive labels, updates to archival forms 
• Making copies of any supporting electronic data  
• Handling off-site storage as applicable.  

On-Site and Off-Site Record Storage Locations 

For healthcare records, you have two storage choices: on-site or off-site.  

If you store records on-site, storage must be access-controlled, and all records must be stored appropriately to ensure integrity and preservation, minimize deterioration and facilitate timely retrieval. All original paper records should be stored in secure, fireproof filing cabinets or appropriate containers, like folders, binders, weather-proof envelopes, cases or boxes. 

If you decide to store records off-site, make sure to use a qualified contractor specializing in off-site medical records storage. Quality should be involved in sending records off-site. All records should be assigned a unique number or other appropriate identifiers which your site must maintain.  

Records should be sent off-site appropriately grouped by record type. This is important because at some point, you might need to retrieve them. And you generally don’t have much notice to retrieve something. It’s generally an immediate need or within 24-48 hours, so if you don’t know where the records are or how they are organized, you won’t be able to produce them as you need to. That’s a problem.  

General Guidelines to Reduce Risk in Records Retention 

Healthcare record retention is governed by federal and state laws, requiring that records be kept for a specific period for patient access, legal protection, and compliance.  

Your organization should operate under the basic requirements for retaining records unless otherwise specified. Use these general guidelines to ensure your processes are set up for retention compliance: 

• Without a specified retention period, a minimum period of 10 years should be used.  
• Once the defined retention period is reached, samples and records may continue to be maintained, returned, transferred to the appropriate owner, or destroyed.  
• Do not destroy anything without appropriate approval from the functional owner.  
• Record destruction must be appropriately documented to denote the end of the life cycle. 

What’s Your Next Step? 

When you have these processes and practices in place, records retention will be a lot more efficient and a lot less stressful.  

Want more ideas for optimizing compliance and quality? You’ll find guidance in these popular articles. 

• Four Ways to Integrate Compliance with Safety/Quality Efforts 
• Best Practices for Better Training in Healthcare Compliance
• Integrate Self-Awareness into Healthcare Compliance Programs: 18 Tips  

Andrea has taught first grade in Willoughby, Ohio for 27 years in the same classroom that she attended school as a child. She earned a Bachelor of Science in elementary education with a minor in language arts from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

John builds and fixes quality departments, while currently thriving as the Administrator & Director of Quality, Risk Management and Compliance at River Vista, a behavioral hospital in Columbus, Ohio.

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The Q-Kids – John R Nocero and Andrea L Bordonaro – are experts at everything quality, regulatory, education training and compliance and love sharing their knowledge on YouCompli.

Follow them on LinkedIn – for more quality content or send them a message – they’d love to hear from you.

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The post Hoarders Need Borders: Quality’s Role in Healthcare Record Storage  first appeared on YouCompli.

In this blog, learn how to go on offense following a regulatory compliance audit or inspection, so you’re well-prepared for the next one. Using sports training analogies, the authors present a better way to handle ongoing inspections and audits in healthcare systems.  

If you play us in basketball, we’re going to run the fast-break transition offense at you, and we will tell you right now; you don’t want to play us two on two. We know our biggest strength – namely that conditioning kills. Savage speed plus unlimited endurance equals an unstoppable force.  

The fast-break transition offense we use is inspired by the 1990 UNLV Running Rebels basketball team. This high-tempo strategy aims to score before the defense can get set. It involves pushing the ball down the court immediately after gaining possession and creating scoring opportunities through numerical advantages and defensive mismatches.  

You can apply the same strategies when managing audits and inspections.  

What Drives Healthcare Audits and Inspections? 

Audits and inspections are regular occurrences in healthcare systems. A number of factors influence how often and what kind. 

• Internal vs. External: Healthcare organizations conduct their own internal audits monthly, quarterly or annually. 
• Regulatory Bodies: Government agencies conduct their own audits, with the number depending on things like budget and staff. 
• Risk and Regulation: Frequency may increase if issues are discovered or when major changes are made to regulations. 
• Organization Size: Larger organizations often have more complex auditing needs, potentially driving more frequent audits. 
• Staff Turnover: High turnover can trigger more frequent audits to ensure consistency. 

What’s Your Playbook for Regulatory Inspections and Audits? 

Most healthcare systems have good reason to believe that a regulatory inspection, sponsor audit or other scrutiny could appear at any time, announced or unannounced. It’s accepted that the standard technique for managing these visits is ongoing vigilance.  

At her presentation on “How to Be Your Own Internal Monitor: A Guide to Monitoring Your Own Studies” at the ACRP 2025 conference, Ann-Marie Jacobson, CCRP, Senior Research Affairs Specialist at Tufts University School of Dental Medicine, said “Because of the unknowns about inspections and audits of in-progress or completed clinical trials, it is important to make sure that all study materials are always kept accurate, current, and explanative of the study activities to date.”

“You always need to be asking yourself, if the Food and Drug Administration (FDA), sponsor, or IRB came in right now and selected a current or recently closed study for examination, would everything be ready?”  

She explained that at her institution, study coordinators “regularly conduct audits of regulatory binders, subject folders, case report forms (CRFs), payment logs, and enrollment/screening logs. These are coordinators who are separate from the clinical team, to ensure that fresh perspectives are always present.” 

We don’t disagree with her, but we wouldn’t call that a fresh approach. Rather, we think that ongoing vigilance should be the standard in healthcare compliance, like a basketball team needs the fundamentals of solid shooting, dribbling and passing.  

Changing Audit Landscape Requires a New Game Plan 

The current healthcare audit landscape is shifting and shifting quickly. Back in late 2024 and even earlier this year, federal and state auditors would arrive and investigate one complaint at a time. They’d come in specifically for one reason or to investigate a particular incident, talk with a couple of staff members, and then summarize their findings and leave.  

Now, we’re hearing differently. Just this week at one of our collegial facilities, an investigator came in to investigate about 10 complaints in various areas, from documentation, to patient care and the like.  

To diligently investigate complaints of this type and volume, the auditor or inspector is probably going to be there on-site for a week or more. They will gobble up valuable conference room space, staff time and basically throw your whole operation into a tizzy due to the heightened emotional state.  

What’s your game plan for audit readiness now? 

Fast Break Offense for Compliance Audit Readiness 

How do you combat this? Well, if you use the key principles of a fast break offense, you will be prepared and conditioned. We’ve adapted these three techniques to the compliance game, to make champions of your team. 

1 – Push the Pace 

In basketball, coaches encourage players to maintain a fast pace and recognize when to initiate the first trigger. In an audit, this means anticipating what the auditor is going to ask and getting ahead of it before they bring it up.  

Pre-audit prep meetings and ongoing reviews of your events make this work, but you can’t just do a pre-audit meeting when an inspection is scheduled. You need to regularly schedule pre-audit meetings, so you’re always prepared.  

I know most organizations don’t do this. But we do. Which is why we have covered things so thoroughly that we can go quickly and get the auditor what they need and then move on to the next question.  

2 – Strength in Numbers 

In sports, we recognize numerical advantages, such as 2-on-1’s, 3-on-2’s or 4-on-3’s and then capitalize on these circumstances through drive-and-kick sequences. Drive the ball to the basket and when the defense collapses on the person with the ball, you kick the ball out to an open teammate to hit a jump shot.  

Within audits, scoring means answering auditors’ questions with the best players you have. You create a numerical advantage by bringing in multiple people to meet with the auditor at the same time and kicking facts around like you would move the ball to score.  

3 – Continuously Practice Good Habits Across the Team 

Lastly, you need elite conditioning habits in sports and in compliance. To run the fast break effectively, you can’t get tired. Imagine unleashing an endless barrage of offense and staying so diligent to this effort that teams know it’s coming and still can’t stop it.  

The team with the most dialed-in offense is usually the most capable, but you need to have players who can react “lag-free” or win their first three steps to capitalize on numerical advantage. The only way to get good at this is to continually work on it.  

Quality and compliance preach continuous improvement, but how often do you do make the effort? How often do you stay late at work, just because? How often do you run more meetings or make everything tighter?  

Chances are zero times, but I will tell you right now that we do. So, if you get into an audit with me, by Day 4, I am still working with a full gas tank, but the auditor isn’t because they went home and “Netflixed“ while I slept. Get your whole team committed to elite habits, and you are unstoppable.  

Prepare Your Compliance Program for the Win 

By reinforcing these principles and working on conditioning and decision making, teams can create more scoring opportunities. And just as a prepared team can force the defense into difficult situations, a well-prepared compliance team can “force” the auditor into zero-findings and more quality inspections.  

Download a PDF Version of the Tip Sheet

Create Compliance Scoring Opportunities 

If you’re interested in more ideas for building a strong compliance program, read these resources next. A strong compliance culture is the foundation of a strong program. 

10 Tips for Building a Compliance Culture in Healthcare 

Earning recognition as a value creator and establishing a healthy culture can be challenging. Yet as these 10 tips show, you can successfully shape culture to help the larger organization better manage and control risk. 

Healthcare Compliance Culture Means Doing the Right Thing at All Levels 

A culture of compliance isn’t just a platitude. It really does exist. Those organizations with a strong culture of compliance and an effective compliance program are the ones with engaged clinical and operational leaders. 

A Culture of Compliance Through Proactive Decision-making 

A culture of compliance is critical to effective regulatory change management. Find three steps to help your leaders make decisions more proactively.   

Andrea has taught first grade in Willoughby, Ohio for 27 years in the same classroom that she attended school as a child. She earned a Bachelor of Science in elementary education with a minor in language arts from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

John builds and fixes quality departments, while currently thriving as the Administrator & Director of Quality, Risk Management and Compliance at River Vista, a behavioral hospital in Columbus, Ohio.

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The Q-Kids – John R Nocero and Andrea L Bordonaro – are experts at everything quality, regulatory, education training and compliance and love sharing their knowledge on YouCompli.

Follow them on LinkedIn – for more quality content or send them a message – they’d love to hear from you.

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27 Ungated Resources for Compliance Leaders and Teams 

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.

Visit Now

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The post With Compliance Audits, The Best Defense is a Good Offense  first appeared on YouCompli.

You Can’t Manage What You Can’t See 

I get into the hospital about 5am every day. I go to intake and get the daily census sheet and report it out to the providers. I walk upstairs and I get my census sheets for all four units. I call in a fourth provider if needed. I review my e-mails.  

But at 7:30 am every day, I round. No exceptions. Weekday. Weekends. Holidays when I am supposed to be off. Doesn’t matter. I round. It has to be done, because I can’t manage what I can’t see.  

You Need to Manage Healthcare Risk 

So many times, compliance administrators and quality leaders sit in their office and manage through e-mail. Say they are too busy. Too many things to do. Yeah, too many meetings. But the truth is, you need to manage risk. 

Risk comes in many forms . Financial. Patient-related. But the biggest unforeseen risk to me is reputational. If you don’t have a reputation for offering the best patient care while keeping people safe and patients receiving benefits from treatment, you won’t be successful. You won’t make money. You won’t care for patients. You need to see it. Firsthand.  

You can’t manage what you can’t see. Here’s how I round.  

What We Look for During Compliance Rounding 

I walk onto the units through the front entrance and immediately talk to the charge nurse.  

• Do you have enough staff?  
• Is everyone listening to you?  
• How is your census?  
• Do you have any events to report?  
• What is the “temperature” of the unit?  

I then walk down the hall and look in everyone’s room. Are the doors locked? Any ligature risks? Any contraband – things like cups, extra linens, things that someone could harm themselves with? You can’t manage what you can’t see. I walk into each room and just look.  

• What is its condition?  
• Are there any screws loose?  
• What does the milieu look like? Is it calm?  
• Are patients interacting with each other?  
• Are they respectful?  

Then up to all the techs. Same questions, plus ones like these: 

• Have patients gotten showers?  
• Are you tired? Do you need to break?  
• What do observations look like? Are they up to date?  

I then walk through the nurse’s station to the sister units and do the same thing. Same questions. Then downstairs to the other two units. Same thing. Same questions.  

You can’t manage what you can’t see. It takes about 45 minutes total, and it’s the most important part of the day. We have cameras, and I could look at the cameras and do this. But so much would be missed. You need to get onto the units. Why? Because you can’t manage what you can’t see.  

Why In-Person Observation Is Valuable Compliance Practice 

There are three main reasons why I do rounding and in-person observation:  

1. Presence: I have to have a presence on the units. Staff need to see me and see me holding them accountable. They know I’m going to come by every day. Same time. They need to be ready. No questions. No excuses. Plus, it shows I care. I do care about every member of the staff. I want them to get used to seeing me on the floor. Pull me aside. Tell me things. That’s important.  
2. Safety: No one should feel unsafe here, so I’m always looking around for contraband or things that patients can use to harm themselves. Cups and linens as I said but there are things that sometimes make it up to the units. Like shoelaces for example. Now, you take it for granted. Loop, swoop, pull and tie your shoes. A self-harming patient can see that as something more. I look at the environment, too. A loose light or a loose screw can be thrown or even swallowed. You need to stay on top of it. If I see something, I tell my Plant Operations Director and put in a work order to have it fixed immediately.  
3. You can’t manage what you can’t see: This is the most important reason and the one I keep bolding. The only way to know what is going on is to be present. Management by walking around is a thing. When I changed a process a couple months ago, the staff was outraged. We can’t do this, that or the other. Then I walked the units. People on phones. Laughing. Looking calm. You ain’t stressed. That changed fast. Funny how that happened.  

Get Real-Time View of What’s Happening in Your Organization 

Only by being present can you get a real-time view of what’s done, what’s stuck and what is slipping through the cracks. Visibility is power. And I finished this round at 7:28. Two minutes to get upstairs, where they’re also expecting me.  

More Resources About Compliance and Risk 

Ready, Set, Go! Identifying Emerging Risks in Your Annual Compliance Workplan 

Before moving on from this year, it’s important to take time and get feedback from business partners to ensure an “outside-in” perspective is included in your 2026 plan. Compliance expert Jenny O’Brien, JD, MCHDS, CHC shares proven practices.  

The Why, What, Who, and When of Healthcare Risk Assessments   

Sharon Parsley, JD, MBA, CHC, CHRC discusses risk assessment from a “why, what who, and when” perspective. She also looks at ways that you, as an effective compliance officer, can lead this process with your colleagues. 

Andrea has taught first grade in Willoughby, Ohio for 27 years in the same classroom that she attended school as a child. She earned a Bachelor of Science in elementary education with a minor in language arts from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

John builds and fixes quality departments, while currently thriving as the Administrator & Director of Quality, Risk Management and Compliance at River Vista, a behavioral hospital in Columbus, Ohio.

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The Q-Kids – John R Nocero and Andrea L Bordonaro – are experts at everything quality, regulatory, education training and compliance and love sharing their knowledge on YouCompli.

Follow them on LinkedIn – for more quality content or send them a message – they’d love to hear from you.

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The post Risk Visibility Isn’t Optional in Healthcare Compliance  first appeared on YouCompli.

This blog explains how to make healthcare quality education programs more effective through focused efforts. It’s about quality, not quantity. Focus on the fundamentals: establish clear policies, learn from past inspections, and create education programs that meet both regulatory requirements and employee development needs. 

As the authors dive into how compliance can enhance quality initiatives through education, they also explain why training need not be complicated. The blog makes its point with a fascinating tale of the value of knowing exactly where to focus your “chalk mark,” if you will. 

Make Your (Chalk) Mark — Why You Need to QC Your QA 

Sometimes people want to make their quality practices so hard. No, it’s true.  

Before you even implement your program, you study the Seven Elements, your competitors, your competitor’s competitors, and so forth, when really, it’s easier to implement and course correct. It’s overkill. 

No wonder people have no real idea what quality is. Every week when we present during new employee orientations, I always ask, what is quality? The most common answer is, doing it right. According to what? The requirements. Which requirements? There are many. Well, all of them? No. 

Yes, quality is hard. 

Measuring Your Quality Programs Too Much? 

You also make measuring your quality program so hard. Tracking is ongoing, anticipatory and retrospective to identify how organizations are performing, including where and why facility performance is at risk or failed to meet standards.  

You attempt to quantify your quality program by: 

• Collecting and analyzing data 
• Measuring processes and systems for effectiveness and efficiency 
• Identifying undesirable patterns or trends 
• Making changes that improve performance and safety 
• Reducing risk of safety events and demonstration of best practices 

What about this level of preparation? Also no. It’s overkill. 

Overloading Quality Training 

Hear us out – we’re not saying the above is wrong, but it’s way too much right now. It’s like giving someone vanilla ice cream, savory peanut butter topping, fluffy marshmallow, hot fudge, chocolate sprinkles and Reese’s Pieces candy. There’s time for that, but it’s not the standard. Vanilla ice cream works just fine most days, and when you just give someone ice cream, suddenly everyone has a ball.  

You probably already have a quality training program; otherwise, you wouldn’t be reading this article. What people don’t think about is training with employees who have TikTok attention spans. (Put down your phone. We know you just picked it up.)  

You don’t need all of this. You need less. You need to QC your QA. That is, quality check your quality assurance. Where is the real value of the training? 

QA + QC = QM 

Before we go on, let’s clarify what these acronyms mean to better understand how they work together for quality management (QM). 

Successful quality management requires both QA and QC. Both work together to ensure repeatable outcomes and quality patient care. 

Where to Start Improving your Healthcare Quality Training 

Don’t overcomplicate your quality agenda. More doesn’t always mean better. Build a quality education program that works. That means covering the basics well, instead of piling on secondary content and details. 

To improve quality training, start by prioritizing policies. It’s essential to blend mandatory policies and regulations (the “need-to-haves”) with employee requirements and skill development (the “want-to-haves”).  

Also review recent inspection reports from auditors, inspectors or regulators to identify areas of deficiency and opportunities for enhancement.  

By focusing on these fundamentals — establishing clear policies, learning from past audits, and designing educational programs that address both regulatory demands and employee competency— you foster a more effective and compliant quality training initiative that ultimately enhances patient care. 

$10,000 Chalk Mark Illustrates the Value of Focus 

You’ve heard the old story of the engineer who charged $10,000 for fixing a machine — $1 for turning a screw and $9,999 for knowing which screw to turn. According to Ramirez (2025), this isn’t just a fable. The story is real — and the man behind it was Charles Proteus Steinmetz (1865–1923), one of the most brilliant, yet often overlooked, engineers in history.  

In the early 1920s, Henry Ford, the king of industrial mass production, found himself facing a major crisis. At his famed River Rouge Plant in Michigan, a massive, custom-built generator — critical to keeping the entire factory running — broke down. Ford’s best engineers tried everything to fix it. They disassembled parts, checked wiring, replaced components — but no one could figure out the root cause. 

He called Steinmetz, who arrived asking for a notebook, pen and cot. He sat by the machine for two days. After 48 hours of meticulous study, Steinmetz asked for a ladder, tape measure and a piece of chalk. Climbing carefully up the side of the massive generator, he measured a specific point, then marked it with a simple “X.” Turning to the exhausted engineering team, he said, “Take off this panel, unwind the coil from this exact point, and remove 16 turns of wire.”  

Skeptical but desperate, the team obeyed. Moments later, the generator roared back to life — as strong and steady as the day it was installed. A few days later, Ford received an invoice from Steinmetz: Total Due: $10,000 

Shocked by the steep cost, Ford requested an itemized bill. Steinmetz replied with legendary precision: 

• Making chalk mark: $1 
• Knowing where to put it: $9,999 

Our point is, know where to put your chalk marks. Where should you focus quality education to fire up the generator and keep compliance running correctly? 

Chalk It Up to Experience 

We can take our QC data and use it to maintain and improve education programs. We generally make our “chalk marks” in one of three categories. These are areas where focused attention has the best return for quality programs:  

Where to Use Quality Control for Quality Assessments: 

• Teacher education: Use QC programs to assess a teacher’s knowledge, skills, attitudes and values to predict their suitability. Also include systematic reviews like self-evaluations, external evaluations and learner assessments.   

• Quality management: This refers to policies and systems to maintain and improve the quality of education and research. Quality management can help clarify responsibilities, work processes and improve transparency.  

• Curriculum development: QC in curriculum development ensures that actual results are close to desired results. In academia, this includes student outcomes, such as how well students perform at different grade levels, and what they can do when they graduate. Data is collected in a variety of ways, including scatter diagrams and control charts.   

The goal is to pinpoint areas for improvement that will deliver a big impact on your investments in quality programs.  

Use QA-QC Synergy to Master Quality Training 

Steinmetz’s story isn’t just a quaint historical anecdote — it’s a powerful reminder about the real value of expertise, experience and deep knowledge. Steinmetz’s chalk mark wasn’t just about turning a screw. It was the result of decades of learning, endless experimentation, and a mind capable of visualizing forces that others couldn’t even detect. 

We understand the balance is delicate, because decision-makers always prioritize long-term system improvements (through QA) over short-term fixes or validations (through QC). But when you need a QC approach, you cannot use QA.  

You need a reactive approach to identifying defects, which involves inspection, testing and verification of the product or result to ensure it meets the specified standards. QC is about detecting and fixing defects after the process has occurred.  

You know you have a training program. How are you teaching it? Where should the chalk mark go? In today’s world, when information seems abundant and skills are often commoditized, the story of Steinmetz reminds us that true mastery is rare — and priceless.  

Think of your quality programs in the same way, as needing assessments to identify gaps, deficiencies, or areas for improvement. Then use your mastery to bring focus to quality education.  

More Resources about Quality and Compliance 

• Building a Quality Education Program That’s Good Enough 

• Healthcare Compliance Is Everyone’s Business: Legal, HR, Quality 

• QA-QC-QM – Quality Education for an Effective Quality Management Program 

John R. Nocero, Ph.D., and Andrea L. Bordonaro, MAT, blog on LinkedIn as “The Q-Kids,” discussing everything related to clinical research education, inspiration, and professional connection. 

John is the Director of Quality at River Vista in Columbus, Ohio. He has worked in clinical research since 2003 and is inspired by the Irish professional wrestler Becky Lynch, whose personal and professional story centers on achievement, tenacity, grit, and overcoming adversity.  

Andrea has taught first grade in Willoughby, Ohio for 25 years. She earned a Bachelor of Science in elementary education from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

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The post Elevate Healthcare Quality Training: Focus, Not Filler  first appeared on YouCompli.