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.
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When a new regulation or update is enacted, the clock starts ticking toward its inevitable effective date and another compliance deadline. Regulatory change management is a moving target with constant deadlines and uncertain task status.
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This is the first article in a series on medical necessity — an area that many compliance programs struggle with. In this piece, we explain 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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For healthcare compliance leaders, financial literacy is not optional. Compliance risk often hides in the fine print of financial data, making literacy a prerequisite for effective oversight.
To identify anomalies or potential regulatory “red flags,” compliance officers must move beyond a high-level view of healthcare finance and understand how clinical operations translate into financial entries.
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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.
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In every organization there is a moment where the quality department becomes either the trusted operational partner or the operational roadblock. The difference tween 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.
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On a daily basis, compliance officers are asked to find solutions to a variety of operational requirements. For example, consider a regulatory change requiring the organization to adjust an operational process in order to bill for a particular service. In this case, the solution must be compliant and operational-friendly, but who’s responsible for making that happen?
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The revenue cycle is the process that starts with a patient’s initial appointment and ends with full payment for services. It encompasses all the administrative and clinical functions that contribute to collecting patient service revenue. For healthcare organizations that provide services to patients, the revenue cycle is the organization’s financial lifeblood.
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“When it comes to the compliance program, effective communication is essential for building strong relationships, resolving conflicts and gaining buy-in. One of the most valuable interpersonal tools to help you achieve these goals is assertive communication. It allows you to express your thoughts, needs and boundaries in a clear and respectful manner.”
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