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.

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.

Healthcare compliance leadership requires choosing between the “hard” of stagnation and the “hard” of growth. This post by John R. Nocero and Andrea L. Bordonaro explores how to move beyond basic regulatory tasks toward strategic Revenue Integrity and Operational Excellence. 

Regulatory compliance leadership isn’t for the faint of heart. Every day, leaders in our field face a fundamental choice that dictates the future of their organizations and their careers. It’s a choice between two distinct types of “hard.” 

One path leads to a plateau of administrative burden, while the other leads to a breakthrough in operational excellence. To move the needle on key compliance metrics, you must decide which challenges you’re willing to embrace. 

The Big Job of Regulatory Change Management 

Regulatory change rarely lives in one department. It touches:  

• Compliance  
• Revenue cycle  
• Legal 
• Clinical operations  
• IT 
• Quality 

Someone must translate regulatory language into operational tasks that those teams can execute. That translation step is where many organizations struggle. Well, guess what? You’re the translation step. 

Someone must translate regulatory language into operational tasks that those teams can execute. That translation step is where many organizations struggle. Well, guess what? You’re the translation step. 

Pick the Hard Work and Then Do It 

The compliance professional’s goal is to move metrics. Period. Whether it’s an outcome of no findings during a state inspection, ensuring everyone is signed off on education and training modules, or the weekly operational numbers posted for the entire organization to see, it’s your responsibility You know the work needs to happen. The challenge is getting the organization aligned around it. And that’s hard. 

Your organization’s leaders trust you to handle it, and they probably see you as capable of doing more. This visibility is an advantage, especially if you want to move up in the organization. But be aware, because corporate and everyone else is watching, looking for cracks in the armor or making you out as the target.  

Our advice? Choose your hard. Here’s how.  

Choose Your Hard: Two Options  

We all want an easier professional life. Less stress from daily meetings. More happiness from the validation of receiving praise from a job well done. Fewer complications from multiple people coming to your door every day to solve problems that aren’t yours.  

Here’s the truth nobody likes to admit: There’s no easy path. There’s only a choice between hard options. So, choose wisely.  

As we see it, you have two options: 

Option 1: Keep Doing What You’re Doing: The Administrative Burden of Stagnation 

This isn’t difficult. You’re basically choosing to do the same things you’ve been doing in the same manner. Keep leading the daily morning compliance meeting in the same style. Keep walking through the units waving and shimmying around but not really being authoritative or looking for issues. Talking to employees but not finding anything out, just basically wasting time. 

And please, avoid the hard conversations around people constantly interrupting you with their problems instead of doing what you get paid to do.  

This is hard, but not for the reason you think. This is hard because, well, we know you, you’re busy, but not productive. You are seen, but you aren’t really doing anything. You think you’re managing, but you’re really just walking around. 

You Get Credit for Moving the Needle, Not for Inertia 

You also think you should be promoted and moved up for doing what you’re supposed to do.  

Here’s the hard truth. You don’t get credit for the things you’re supposed to do. If you’re supposed to lead orientation, write policies, make presentations, all that is in your job description. It’s a basic function of your job. You’re not getting additional credit for that. You get credit for moving the needle, not stagnation.  

This version will feel easy in the moment. But over time, it becomes a cycle. Anxiety creeps in. Stress builds quietly. Communication gets messy. You start telling yourself little lies to stay comfortable. You get moments of happiness, but they don’t last because they’re built on escape, not stability. 

When a compliance department functions as a separate silo rather than a strategic partner, the friction is constant. You’re working hard, but you are not working toward a breakthrough. You are merely surviving the administrative weight of healthcare regulations. 

Option 2: Face Challenges Head-on: The Discipline of Operationalizing Compliance 

The alternative is the “hard” of growth. This involves the difficult work of Revenue Cycle Management (RCM) integration, fostering cross-functional alignment, and ensuring that compliance is viewed as a driver of healthcare quality and patient safety. 

It takes discipline to move beyond the checklist and into this strategy. It’s “hard” because it requires changing the culture of an organization, but it’s the only path that leads to: 

• Sustainable Revenue Integrity: Moving from reactive auditing to proactive prevention.
• Enhanced Patient Safety: Aligning regulatory requirements with frontline clinical care. 
• Professional Authority: Establishing compliance as a core pillar of the leadership team. 

Cut the noise. Reduce the dopamine overload. Sit with discomfort instead of running from it. Say the hard things. Build better habits. Run different meetings. If your boss is giving you a directive that you have to go and talk to the director of nursing and get his or her staff to carry out a particular order, don’t walk up to them and go “Hey, boss, wants you to do this” and tell them exactly the same order that was told to you. That’s not changing. That’s parroting.  

You need to do that a bit differently, such as “boss wants your team to do XYZ. Do you know how to do this? Does your team know how to do this? What are the gaps? What can I do for you right now?” 

The Hard Path Is Uncomfortable but Pays Off Over Time 

See the difference? It’s subtle, but effective. Basketball fans can think of it as the difference between telling your basketball team to run the triangle offense and perfecting the triple-post with all your front court repeatedly until it’s second nature, creating multiple scoring options based on defensive reactions. When you repeatedly do the hard thing, it pays off over the long term. 

This hard path is uncomfortable, and at first, it feels worse, not better. It’s hard to sit in the discomfort. But over time, something starts to change. Your brain slows down. Your emotions stabilize. You stop needing constant stimulation just to feel okay.  

And one day somewhere down the line, you realize: You’re not chasing happiness anymore or trying to be the part. You don’t need to wear a three-piece suit to the corporate board meeting. You can wear a Roman Reigns OTC crewneck. You don’t have to pretend to be the part. You are the part. And you are just experiencing it. 

Choosing the Tough Option Compounds the Benefits 

The tricky part about Option 2 is that it doesn’t feel like it’s working at first. That’s where most people quit. Option 2 is harder. But it compounds. It’s the difference between escaping your life and actually building one you don’t need to escape from.  

Be a long gamer because taking the “easy” path now often becomes the hardest life later. And the hard path now? That’s the one that sets you free. 

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 The Compliance Leadership Paradox: Why You Must Choose Your Hard  first appeared on YouCompli.

Six Capabilities Needed to Drive Scalable Change Management  

For healthcare compliance leaders, the challenge isn’t just lack of information. It’s a lack of time. 

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. 

Without the right tools and systems, all that many compliance leaders can hope for is a link to a government website buried in your inbox from a listserv, or a lengthy regulation that needs reviewed to get started. 

That’s why a modern regulatory change management (RCM) system should do more than just notify you when regulatory changes occur.  

To be truly useful, RCM software needs to transform complex regulations into actionable tasks that clinical and administrative teams can execute without needing law degrees or spending a lot of time extracting all the need-to-implement details.  

Beyond the Regulation: 6 Non-Negotiables for Regulatory Change Management Software 

The shift from uncertainty and static reading material to active management and confident compliance is critical for any modern healthcare system. 

If you’re evaluating a regulatory change management (RCM) solution, look for these six essential capabilities to move your team from “reading” to “doing.” 

Top Requirements for Regulatory Change Management Processes: 

1. Expert-Led Analysis for Continuous Regulatory Intelligence and Monitoring 

2. Efficient Relevance Identification and Assessment Saves Time 

3. Automated Assignment Mapping to Departments, Assignees and Monitors 

4. Workflow Accountability and Oversight for Defensible Audit Trail  

5. Proactive Notification and Escalation Reduce Manual Steps 

6. On-Demand Analytics and Reporting for Actionable Data 

1. Expert-Led Analysis for Continuous Regulatory Intelligence and Monitoring 

Many compliance solutions just offer a link to a government website. That’s not enough for healthcare teams that are already stretched and overworked. Asking a pharmacy director or a head of nursing to read a hundred-page statute on drug pedigree requirements isn’t a sustainable compliance strategy. 

Can It Do the Heavy Lifting? 

A true regulatory change management solution does the heavy lifting for you. A best-in-class solution provides not only the source regulations, but analysis for those regulatory changes relevant to your organization or department.  

This analysis serves as a bridge between the legal language of the regulators and the daily operations of the hospital. Model procedures outline updated provisions of regulatory changes, that is – the requirements, in an operational way.  

From “Legalese” to “Actionable” 

For instance, if a new rule regarding patient privacy in telehealth is released, your software shouldn’t just notify you of the change. The tool should provide a comprehensive overview of what’s included in those changes for you to operationalize. The overview provides all the need-to-know information combined with workflow to assign work and track that it gets done.  

By clearly presenting these tasks, the system reduces the cognitive load on your department heads and ensures nothing is overlooked in the transition from “legalese” to “actionable.” When your team knows exactly what they need to do, the risk of non-compliance drops significantly. 

2. Efficient Relevance Identification and Assessment Saves Time 

Not every regulatory change applies to every organization. Identifying if a regulation or part of one that applies to your organization can take time, resources, and effort to read and see if, how and what applies. A regulatory change management solution should facilitate identification of what’s relevant. Then you can put a quick focus on regulatory changes that specifically impact your organization.  

Capabilities That Reduce Effort Spent Reading Regulations 

Regulation Relevance Check: Your software should guide you through a relevance check and allow you to quickly (within a minute or less), identify if a regulation is relevant or not. 

The “Don’t Know” Button: If a user is unsure of how to answer a question to determine relevance, the software should provide the ability to assign questions to additional staff who have information needed to answer yes or no. Look for a workflow solution that allows you to reach out if you’re unsure of the answer. 

Once the subject matter expert provides their response, you decide if the requirement is relevant as assisted by the question tips. These walk you through the relevance decision-making process.  

The workflow process ends at Step One for requirements that aren’t relevant. It progresses to task assignment and review only for the regulatory work your organization actually needs to get done.  

3. Automated Assignment Mapping to Departments, Assignees and Monitors 

In a busy health system, the person doing the work isn’t always the person who needs to verify that it was done. That creates blind spots and broken workflows. 

Regulatory change management (RCM) software avoids this by allowing you to: 

• Automate Assignments by Department: Assign requirements based on staff department (e.g., pharmacy, radiology, professional fee revenue cycle). 

• Differentiate Roles: Software distinguishes between an Assignee (the person doing the work) and a Monitor (the person providing oversight/cc’d). 

• Set Audit Trails: Every comment and status change should be time-stamped with the username to ensure a defensible record for future audits. 

RCM software reflects your organization’s reality through distinct user roles and automated workflows to them. These roles define who has the hands-on responsibility and who has oversight responsibility, creating a clear chain of command. 

The Role of the Monitor 

The monitor role is an essential feature of modern change management software. Think of this as a structured “cc” function. A department director might need to see that a change is occurring without being the one to upload proof of completion. This keeps leadership informed and accountable without cluttering their daily task lists.  

For instance, a Chief Nursing Officer might want to monitor the progress of a new patient safety protocol across multiple departments without being responsible for each individual task. This separation of duties is a hallmark of a mature compliance program. 

Smart Duplication for Scalable Efficiency 

Also look for “smart duplication” in regulatory change software. For example, if you manage five different hospitals, you shouldn’t have to manually create five identical tasks. An “Assign to All” feature lets you create unique, trackable requirements for each location simultaneously.  

Each hospital administrator receives their own task, but the corporate compliance office can see the progress of all five locations in a single view.  

This maintains centralized oversight while ensuring local accountability. This feature is particularly useful for large health systems that need consistency across dozens of locations and departments while allowing for local execution. 

4. Workflow Accountability and Oversight for Defensible Audit Trail 

The saying goes that if it wasn’t documented, it didn’t happen, and sometimes that applies to healthcare audits. An effective audit trail should be able to reconstruct the entire decision-making process for any given regulation. 

Your software shouldn’t just track completion status. It should capture the entire story of your compliance efforts, providing a clear path for auditors to follow.  

Centralized Commenting Backs Up Workflow Decisions 

Centralized commenting is a key part of a defensible audit trail. Compliance leaders can move away from fragmented check-in emails and internal chat threads. Instead, all discussions regarding a specific regulation live inside a dedicated task workspace.  

This creates a time-stamped, unalterable record of: 

• Who made decisions 
• What questions were asked 
• When work was completed 

If an auditor asks why a certain policy was changed six months ago, you can provide the exact thread of discussion that led to that decision. This level of transparency builds trust with regulators and simplifies the audit process. 

5. Proactive Notification and Escalation Reduce Manual Steps 

Compliance shouldn’t be a surprise. Proactive notification and escalation ensure that deadlines are known and met. A good compliance management system sends automated reminders well before an effective date passes.  

If a task remains untouched as a deadline approaches, the software should trigger a proactive escalation to supervisors. This ensures potential gaps are addressed before they become regulatory violations.  

Automated escalations remove the need for compliance officers to manually follow up with department heads, saving time and reducing friction between departments.  

Proactive Notifications Improve Efficiency 

A static dashboard is where compliance tasks go to die. Instead, look for a dynamic, proactive system that pushes information to your team. With email integration, direct links from an email notification take users straight to their requirement and task workspace in the software. 

6. On-Demand Analytics and Reporting for Actionable Data 

The Analytics Dashboard is designed for what healthcare compliance leaders need to see: 

• What’s overdue?  
• Where do I need to focus?  
• What do we need to do? 

With one click, see everything happening in the workflow, then export important information into spreadsheets or slides for sharing or presenting.  

The outcomes of using a dashboard to manage compliance workflow are: 

• Efficient, reliable access to real-time, high-quality data 
• Simplicity and ease of use save time 
• Visibility and transparency lead to peace of mind 

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 for details of dashboard information and insights into completed work. 

Next Steps in Your Software Journey: Look for a Partner, Not a PDF Repository 

When evaluating software vendors, ask if the solution actually helps you do the work or does it just give you more things to read. The right regulatory change management software doesn’t stop at sending notifications of regulatory changes. Instead, it actively manages your workload.  

By prioritizing expert analysis, intelligent relevance filtering, and clear role definitions, a good software tool can move your compliance department from an underappreciated burden to a streamlined operational partner.  

A truly effective solution empowers your staff and provides peace of mind to executive leadership. The goal is a culture of compliance where every team member knows exactly what is expected of them and has the tools to achieve it. We share that goal. Reach out if you’d like to know what regulatory change management software can do for you. 

About the Author 

Amy Laufmann, MBA, Client Success Manager at YouCompli, has 10+ years of experience in healthcare compliance leadership and operations in the Pacific Northwest and is passionate about helping healthcare organizations demonstrate the immense value compliance teams provide the healthcare organizations they serve. In her current role, she works with clients to ensure they get the most value out of the YouCompli software and supports compliance leaders nationwide to continuously improve the services and support YouCompli provides. 

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The post What to Look for in Regulatory Change Management Software for Healthcare Compliance  first appeared on YouCompli.

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. 

What does a compliance leader need to understand? Things like: 

• Budgeting and capital planning 
• Internal controls and risk 
• Grant and research compliance  
• Key performance indicators (KPIs) 
• Communication between CFO and compliance officer 

Familiarity with the 14 steps of the revenue cycle is also valuable for mitigating risks associated with reimbursements and 340B compliance. (This topic is covered later in the blog.) 

Where Do Healthcare Compliance and Finance Intersect? 

Regulatory compliance and healthcare finance overlap in multiple ways. Compliance-related areas with a financial angle include: 

• Medicare, Medicaid reimbursement 
• 340B drug pricing 
• Stark Law and anti-kickback statutes 
• Charity care 
• Financial assistance requirements  

What Should Compliance Leaders Understand About Financial Statements? 

To build fiscal literacy, let’s start with some foundational concepts – financial statements. Compliance officers should have a basic understanding of these types of statements: 

1. Balance Sheet 
2. Income Statement 
3. Cash Flow Statement 

1. The Balance Sheet: Assessing Financial Integrity Through a “Snapshot” 

The balance sheet provides a snapshot of an organization’s financial health at a specific point in time, detailing its assets, liabilities and equity. 

Why Compliance Should Care: Monitoring the balance sheet helps ensure that assets are properly recorded, and that liabilities like these are appropriately disclosed: 

• Potential legal settlements 
• Debt obligations 
• Medicare overpayments 

2. The Income Statement: Monitoring Operational Risk Over Time 

Unlike the balance sheet snapshot, the income statement tracks revenue and expenses over a specific period, such as a month or a fiscal year. The income statement puts a focus on total revenue and expenses, and the difference between them, while distinguishing between operating and non-operating items. Those two concepts are compared in the chart below. 

In an income statement, it’s important to distinguish between accrual-basis accounting (matching revenue to period it was earned) and cash-basis accounting (recording transactions only when money changes hands). 

Why Compliance Should Care: By comparing current monthly performance against previous years, compliance officers can spot outliers in revenue or sudden spikes in expenses that could indicate billing errors, “upcoding,” or improper financial arrangements under the Stark Law. 

3. The Cash Flow Statement: Ensuring Operational Sustainability 

The cash flow statement tracks the actual movement of cash into and out of the organization, categorized by: 

• Operating activities 
• Investing activities 
• Financing activities 

Why Compliance Should Care: Understanding cash flow is vital for making sure the organization has liquidity to maintain compliance standards even during times of financial strain. A significant discrepancy between reported net income and actual cash flow can signal deep-seated issues with revenue cycle integrity.  

Revenue Cycle as Regulatory Roadmap 

For a prepared healthcare compliance leader, the revenue cycle isn’t just a financial process; it’s a regulatory roadmap. From initial patient interaction to final collection, each step presents a unique set of compliance risks that can lead to audits, fines or loss of reimbursement if not managed with understanding. 

What Compliance “Trapdoors” to Watch for in the Revenue Cycle 

The revenue cycle is full of complexity, largely fueled by the impact of different hospital types (PPS, critical access, disproportionate share, and tribal hospitals) on Medicare and Medicaid rates. 

While the full revenue cycle has 14 distinct stages, compliance officers should pay particular attention to these “trapdoors” where financial operations must meet strict federal regulations: 

• Front-End Integrity (Scheduling and Registration): Accuracy is paramount to ensure Medicare and Medicaid reimbursements aren’t jeopardized by incorrect patient data or lack of prior authorization. 
• Clinical Documentation and Coding: This is a high-density risk area. Compliance must make sure that coding reflects the actual services provided to avoid allegations of “upcoding” or “unbundling,” which can trigger False Claims Act investigations. 
• 340B Drug Pricing Program: If an organization participates in 340B, the revenue cycle needs rigorous internal audits to establish compliance with drug diversion and duplicate discount prohibitions. The stakes will be even higher if the program undergoes potential changes regarding payment models. 
• Billing and Claims Submission: Errors in this stage directly impact the Clean Claim Rate. More importantly, consistent billing errors for federal healthcare programs can lead to significant liability under Anti-Kickback Statutes or the Stark Law if improper financial relationships are found. 

Monitoring Denial Management at Back End of Revenue Cycle 

A robust compliance program monitors the back end of the revenue cycle as closely as the front. Analyzing denials can reveal systemic issues in documentation or billing practices that, if left unaddressed, represent both financial loss and compliance vulnerability. 

What KPIs Should Compliance Watch as Part of Financial Oversight? 

For a healthcare compliance officer, financial data is more than just a reporting requirement. It’s a proactive tool for risk assessment. By monitoring specific KPIs, compliance teams can move from reactive auditing to strategic oversight and identify operational stressors before they escalate into violations. 

The “Big Four” Financial KPIs for Compliance Officers 

Comprehensive financial oversight should track these four metrics: 

• Operating Margin: This measures whether the organization’s core clinical mission is profitable after all operating and overhead costs are paid. A shrinking margin often leads to “cutting corners” in staffing or documentation, which directly increases compliance risk. 
• Days Cash on Hand: This indicates liquidity. How many days can an organization operate using its current cash reserves if all revenue stopped? Higher liquidity provides the financial “breathing room” to maintain compliance and quality standards even during economic downturns. 
• Clean Claim Rate (CCR): A high CCR (ideally 95% or higher) indicates that claims are being submitted without errors the first time. A low rate is a red flag for systemic billing or documentation errors that could trigger federal audits under the False Claims Act. 
• Payer Mix: It’s critical to understand the percentage of revenue coming from Medicare, Medicaid and private insurance. In many healthcare models, Medicare functions as a “break-even” payer, while Medicaid reimbursements often fall below the actual cost of care, placing additional pressure on revenue integrity. 

What to Know about Budgeting and Internal Controls 

Compliance officers should also distinguish between the Operating Budget (daily/annual clinical operations) and the Capital Budget (typically reserved for long-term investments or items over $10,000). 

To prevent fraud and ensure financial integrity, a compliance program must enforce strict segregation of duties. This assures that no single individual has control over all aspects of a financial transaction, serving as a primary defense against embezzlement and improper financial reporting. 

Using the SBAR Tool to Structure CFO and Compliance Communication 

The most effective healthcare compliance programs are those where the Chief Compliance Officer (CCO) and Chief Financial Officer (CFO) operate as strategic partners.  

However, communicating complex compliance risks in a way that aligns with financial priorities requires a structured approach. This is where the SBAR tool (Situation, Background, Assessment, Recommendation) becomes invaluable for justifying financial decisions and resource allocation. (Download a helpful SBAR template at the end of this article)

Four-Step Method for Financial Advocacy 

Use this four-step method to present compliance needs to your finance team: 

• Situation: Clearly state the immediate financial or regulatory issue.  
  Example: “We have identified a 15% discrepancy in our 340B drug pricing audits.” 

• Background: Provide the necessary context and data.  
  Example: Current Medicare reimbursement rates for these drugs are subject to strict transparency requirements. 
   
• Assessment: Offer your professional analysis of the risk.  
  Example: Failure to rectify this documentation gap poses a significant risk to operating margin and regulatory standing and could trigger a federal audit. 
   
• Recommendation: Propose a specific, data-backed solution.  
  Example: “I recommend an immediate investment in automated tracking software as part of the next capital budget cycle.” 

How Compliance Can Secure a “Seat at the Table” 

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.  

Ready to drive more compliance value? Reach out to see how YouCompli can help.  

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The post Financial Literacy: The “Superpower” Every Modern Compliance Leader Needs  first appeared on YouCompli.

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. 

Question 1 – How do you define value in the context of healthcare compliance? What kinds of value can compliance create? 

Lisa Herota – Compliance has a positive impact on financial, clinical and operational outcomes when we manage compliance well overall, not just by avoiding penalties.  

We help the organization safeguard the mission and reputation by: 

• Protecting revenue  
• Enabling ethical growth 
• Maintaining patient safety 

We do this all while also making our leaders feel more confident. They can make informed decisions through a compliance mindset, versus just worrying about how we’re going to avoid a penalty. 

Q 2 – Can you share examples of how you’ve created value or seen others do it? 

LH – One approach I’m proud of is strengthening organizational trust and reputation by developing a culture of compliance. This happens through:  

• Rounding and being present in the organization 
• Doing trainings  
• Partnering with leaders, medical staff, employees and even patients 

I’ve taken compliance teams from being the department where ideas go to die or the “Department of No” to being seen as a function that engages and supports. We became a resource that leaders want to bring to the table at the beginning of projects and discussions as a support versus just somebody to call when things go wrong. 

Q 3 – How do you measure and quantify compliance value?  

LH – I love data. I preach data, data, data to all compliance leaders. There are lots of different metrics we don’t think about, but many times, we just look at how we avoid fines. 

Actually, compliance has a lot of data for leaders to study. We can:  

• Look at percent of applicable regulations implemented on time.  
• Look at number and severity of audit findings or corrective action plans implemented.  
• Trend reported issues and how quickly those issues were resolved.  

Compliance Metric: Tracking the Near Misses 

Something that compliance leaders don’t think about often enough are the near misses. We usually think about these situations in patient safety and quality. But many times, compliance can help with close calls, and we should track those.  

Compliance Metric: Financial Value from Correct Regulation Implementation 

Common examples of financial value derived from correctly implementing new regulations include: 

• Reductions in external legal expenses 
• Decrease in denials and claw backs or repayments 
• Additional revenue capture  

Compliance Metric: Operations Staff Hours Saved 

You can talk to your operational leaders about how their team workloads benefit, especially if you have good regulatory change management tools with reporting and dashboards. Many times, I’ve tracked the number of hours saved that operational leaders don’t have to spend reading through regulations to decipher and interpret them.  

Department heads save valuable time when we provide them with tools like policy templates, implementation information, and the interpretation of the regulation itself. So, the hours compliance saves other department leaders is a good metric, too. 

Hard for Compliance to Quantify: Harm Avoidance  

It’s difficult for compliance professionals to quantify how they help the organization avoid harm. It’s definitely easier for revenue-generating departments to show their value, because they can measure the revenue they drive.  

But compliance often concentrates on how we avoid fines, and it’s hard to prove we’ve truly avoided something when the attitude is “Maybe we wouldn’t have gotten that fine anyway, regardless of what we do or don’t do.” That’s why I focus on other metrics. 

Q 4 – Who needs to know about the value that compliance creates, and how do you communicate that? 

LH – That’s a great question. There are various levels across any health system or organization that need to know the value that compliance has created, but the way you report it is going to look different based on whom you’re talking to.  

Talking to the Board 

When I’m presenting to my board or board committees, I target risk mitigation trends, assuring them we’ve got this. I use heat maps that show risk rankings, prioritization and key regulatory risk areas. I use implementation rates or key issues identified and resolved. When I’m talking to my board, I highlight how compliance work aligns with the strategic priorities of the organization.  

Talking to the Executive Team 

But when I’m talking to my executive team, I might get a little more granular with how many reduced denials or repayments or how many claw backs we avoided. Also, that metric about saving frontline leaders’ time, because that affects their operational teams as well as alignment with patient safety, quality and patient experience goals. A key metric is showing executive leaders how compliance ties into all the other objectives that the organization is trying to accomplish.  

Talking to Operational Leaders and Frontline Teams 

It’s a very different story when I’m talking to operational leaders or frontline staff.  With them, I focus on how I’m helping them succeed:  

• Fewer surprises related to regulations that apply to them 
• Reduced fire drills from reactive implementations versus steady, methodical implementation of regulatory change. 
• With good policies, procedures and training 

With frontline staff, it’s all about what compliance does. Proving compliance value is about showing them how we:  

• Impact their day-to-day reality. 
• Make changes to protect them and their patients. 
• Help make their work easier and safer. 

Really, it’s all about how we help support them and affect their day-to-day work. 

Tie Compliance Work to Strategic Goals for Value Recognition 

To overcome compliance reporting roadblocks, I go back to tying compliance’s work directly to the organization’s strategic goals. Just connect what we do to what the organization is focused on. Show how what we do impacts quality, CMS, star ratings, financial stability, the growth of new service lines and innovation.  

We need to connect what we do to optimizing and streamlining those goals and processes. 

Q 5 – What feedback have you had about compliance metrics and value? 

LH – One of the stories I love to share is about the day I was presenting a regulatory change management dashboard to my board. The very first time, I showed them that over the course of a year, the compliance team had touched over 535 regulations. It was the height of Covid, and when I presented that dashboard, board members just sit back in their chairs almost with a collective sigh.  

And they said, with the data you present, we can see what’s happened to the organization. We’re not just hoping we’re compliant. Now we can prove it. We can show that the organization truly is operating in a compliant manner. That was one of my biggest takeaways from frontline leaders.  

Other feedback I’ve received includes: 

• “I feel like compliance is supporting and partnering with me, not just telling me no or being a barrier.” 
• “When we streamlined compliance tools, that really helped support compliance functions.” 
• “Compliance saves us time and work by not having to review, interpret and decipher complicated regulations.” 

Leaders feel confident knowing we’re not missing anything and that they’re being supported. 

Be a Confident, Data-Driven Compliance Leader 

Wouldn’t you like to feel the same way about your compliance program? Reach out and we’ll show you some of the compliance management tools mentioned in this blog. 

About the Author 

Lisa Herota is a seasoned healthcare executive with over two decades of experience leading high-impact initiatives in compliance, privacy and health information management (HIM). She brings a strategic, data-driven approach to safeguarding organizational integrity. 

Throughout her career, Lisa has held pivotal leadership roles at several medical systems. Her expertise spans the full spectrum of healthcare operations, from managing complex ICD-9 and CPT coding systems, to overseeing departmental budgets and navigating rigorous accreditation standards. 

Lisa is a recognized expert in regulatory change management and is passionate about transforming compliance from a “policing” function into a proactive business partner. She holds an impressive array of professional certifications that underscore her deep technical knowledge, including: 

• RHIA: Registered Health Information Administrator 
• CHC: Certified in Healthcare Compliance 
• CHIAP: Certified Healthcare Internal Audit Professional 
• CHPS: Certified in Healthcare Privacy and Security 
• CCS: Certified Coding Specialist 

Beyond her technical skills, Lisa is a dedicated advocate for building a culture of compliance. She leverages her background in research and data compilation to provide executive leadership with insights to make informed, ethical and growth-oriented decisions.

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The post Beyond the Penalty: What Metrics Should Healthcare Compliance Officers Track?  first appeared on YouCompli.

Revenue leakage from non-compliance with regulations exposes health systems to compliance risks and penalties. We’ve curated eleven resources to help compliance leaders be better prepared to guide alignment between regulatory compliance processes and revenue integrity goals.

Why Should Compliance Care about the Revenue Cycle? 

Over half of all regulations deal directly with revenue cycle, billing and finance. Most providers still lack an effective system or process to monitor, assess, and validate compliance with those regulations. As a result, these organizations leave themselves open to significant risks, not to mention significant revenue leakage. 

If you need to learn more about the revenue angle of healthcare compliance, these resources are a good place to start. 

Compliance Content by Compliance Experts 

The resources included in this collection Include articles from noted compliance experts including: 

• Shawn Y. DeGroot – CHC-F, CCEP, CHRC, CCPC 
• Maeve O’Neill, MEd – LPC-S, CHC, CDTLF 
• Sharon Parsley – JD, MBA, CHC, CHRC 
• Susan Thomas – CIA, CHC, CPC, CRMA 
• Maya Turner – CPMA, CPCO, CFPC, CPC, CPC-I, AAPC 
• CJ Wolf – MD, CPC, CPC-I, M.Ed. 

Learn from their advice and examples how compliance contributes to revenue performance and launch your own strategies for improvement. 

1. Blog – Mitigating Conflicts of Interest that Drive Profit Over Health  

Integrity First: Mitigating Conflicts of Interest in Clinical Decision-Making 

In healthcare, a conflict of interest (COI) occurs when secondary interests, such as financial ties or institutional goals, threaten to compromise clinical objectivity.  

These conflicts do more than just create ethical dilemmas; they often lead to overutilization of unnecessary tests and treatments, inflating costs for patients and insurers alike. For compliance leaders, addressing COIs is essential to protecting the integrity of the healthcare system and ensuring resources are used appropriately. 

This blog examines the ripple effects of COIs on both patients and providers. It discusses key components of these conflicts and the significant financial impact they have on the entire healthcare ecosystem. 

Inside this resource: 

• Identifying the Triggers: Learn to recognize the financial ties and personal relationships that can bias medical decision-making. 
• The Cost of Overutilization: Understand how unnecessary procedures create financial burdens and exploit the system for gain. 
• Systemic Impact: Explore the broader consequences of COIs, including their role in fraudulent billings. 
• Protecting Objectivity: Strategies for ensuring that clinical judgment remains aligned with the best interests of patients and public health. 

Don’t let hidden interests drive your organization’s clinical path. Read the full blog to learn how to identify and mitigate the conflicts that put your system at risk. 

2. Blog – How to Avoid False Claims Related to Medical Necessity   

Protecting the Bottom Line: Compliance as a Revenue Safeguard 

In the complex world of health system finance, a single coding error can quickly escalate into a multi-million-dollar False Claims Act liability. While Revenue Cycle Management (RCM) focuses on speed and volume, Revenue Integrity ensures that those gains aren’t lost to federal audits or recoupments. 

3. White Paper – Exploring the Four Hot Spots Of the Healthcare Revenue Cycle  

Navigating the Minefield: Mastering the Four Hot Spots of Revenue Integrity 

The healthcare revenue cycle is the financial lifeblood of your organization, but it’s also a landscape filled with hidden regulatory traps. With complexity in payer contracts and government oversight, certain areas have evolved into high-risk “hot spots” that demand immediate, expert compliance scrutiny. 

4. Case Study – Getting It Right: Minimizing Self-identified Overpayments & Maximizing Accurate Billing 

From Regulatory Burden to $400,000 in Savings: The Great River Health Story 

For a small compliance team, staying ahead of complex state coding rules and rapid federal updates is often a losing battle. At Great River Health, this challenge meant spending countless hours manually interpreting regulations, yet the team never felt fully confident that they were catching every risk. They needed a way to move away from constant research and toward decisive action. 

This featured case study explains how Great River Health transformed their compliance program from a source of stress into a vital engine for revenue integrity. By adopting a system that provides validated policy templates and expert regulatory analysis, they shifted their focus from interpretation to implementation. 

5. Blog – Healthcare Compliance is Everybody’s Business: Clinical, Revenue Cycle, IT, Sales and Marketing 

Breaking the Silos: Why Compliance is Everybody’s Business 

To ensure long-term stability, compliance leaders must lead the charge in fostering deep partnerships with clinical, IT, and revenue cycle teams. Compliance can no longer operate in isolation. As governmental and commercial payers deploy increasingly sophisticated programs, the only way to safeguard your organization is through a unified front.  

This blog explores the strategic necessity of internal alliances. It breaks down the specific skills and communication rhythms required to identify systemic risks and avoid the catastrophic penalties associated with “reverse false claims” liability. 

Inside this resource: 

• The Partnership Mandate: Why a strong relationship with your revenue cycle team is your first line of defense against advanced payer audits. 
• Beyond the Surface: Learn how to distinguish between coding-specific denials and medical necessity issues to uncover localized and systemic vulnerabilities. 
• The 60-Day Clock: Understand the critical risks of “reverse false claims” and how to manage the return of overpayments to avoid treble damages. 
• Proactive Governance: How to establish regular cross-departmental meetings that turn compliance from a reactive task into a shared culture of integrity. 

Stop letting departmental silos become a regulatory liability. Read the full blog to learn how to turn every team into a partner for revenue integrity. 

6. Blog – Uncovering $9 Million in Unbilled Services    

The $9 Million Question: How Mock Audits Uncover Hidden Revenue 

Most compliance professionals view mock audits as a shield against fines and regulatory scrutiny. However, when approached strategically, these audits can also act as a powerful engine for revenue integrity. In one striking example, a fresh set of eyes and a few “tough questions” led to the discovery of $9 million in unbilled services. 

This featured blog explores how mock audits do more than just manage risk. They’re a primary tool for building cross-departmental relationships and positioning the compliance team as a high-value partner to the rest of the organization. 

Inside this success story: 

• The “Fresh Eyes” Advantage: Why stepping away from day-to-day tasks to look at the bigger picture is essential for identifying systemic billing gaps. 
• Beyond Revenue Protection: Discover the five strategic benefits of audits, from shaping organizational culture to preventing future penalties. 
• The Power of Simple Questions: See how asking “Do we bill that?” can lead to the biggest dollar-value discoveries of your career. 
• Compliance as a Partner: How to use the audit process to build trust and influence across the business while delivering tangible financial value. 

Stop viewing audits as a burden and start seeing them as an opportunity to prove the financial impact of your compliance program. Read the full story here to learn how to turn your next mock audit into a multi-million-dollar win. 

7. Blog – Compliance Risks Associated with Outlier Payments  

The Chargemaster Trap: Managing the High Stakes of Outlier Payments 

The next resource in our collection focuses on a high-stakes area of reimbursement that often flies under the radar until an audit begins — outlier payments.  

Outlier payments are designed to protect hospitals from significant financial losses on exceptionally costly cases. However, because these supplemental payments are directly tied to hospital charges, they have become a primary target for regulatory scrutiny. If a facility raises its chargemaster prices without clear justification, it can artificially inflate these payments and trigger intense external audits. 

This blog explores the delicate balance between revenue protection and compliance risk. We examine real-world audit findings where simple human errors and system glitches led to hundreds of thousands of dollars in overpayments and potential penalties. 

Inside this resource: 

• The Scrutiny Factor: Understand why enforcement agencies are actively monitoring price increases that lead to spikes in outlier reimbursement. 
• Lessons from the Field: Review the 2020 OIG audit of an Arkansas facility that found over $580,000 in overpayments due to time-tracking and coding errors. 
• The Human Error Risk: Learn how “hardcoded” charges and misaligned supply items can create systemic billing inaccuracies that go undetected for years. 
• Strategic Collaboration: Discover why a close partnership between compliance, finance and reimbursement teams is the only way to safeguard your organization against these risks. 

Stop letting unjustified price adjustments put your hospital at risk for recoupment and penalties. Read the full blog here to learn how to proactively audit your outlier claims and maintain regulatory integrity. 

8. Blog – The Cost of Non-Compliance  

Beyond the Fine: Calculating the True Price of Non-Compliance 

In the budgeting process, the cost of non-compliance is often a forgotten line item until it becomes a hard reality. While hefty fines for HIPAA or Medicare violations are the most visible risks, they’re only the beginning.  

For healthcare organizations, the true cost includes a cascade of legal fees, operational disruptions and long-term reputational damage that can be difficult to quantify but impossible to ignore. 

This piece explores how to move beyond reactive firefighting and toward a model of operational excellence. We discuss how to use Corporate Integrity Agreements (CIAs) as a powerful benchmarking tool to identify systemic vulnerabilities before they lead to federal intervention. 

Inside this resource: 

• The Tangible and Intangible: Learn how to communicate the full spectrum of risk to your board, from immediate settlement costs to the lasting impact on patient trust. 
• Contract Integrity: Focus on the critical importance of auditing physician and medical director contracts to prevent Stark Act and Anti-Kickback Statute violations. 
• A Culture of Excellence: Understand why investing in compliance is not just a legal obligation but a cornerstone of your organization’s commitment to patient care and operational stability. 

Stop viewing compliance as a cost center. Read the full blog to learn how a proactive approach to auditing and monitoring can safeguard your organization’s future. 

9. Blog – How to Avoid Compliance Risk in Peripheral Vascular Reimbursement   

Under the Microscope: Navigating Peripheral Vascular Reimbursement Risks 

Peripheral vascular disease (PVD) reimbursement has become a lightning rod for regulatory scrutiny. With alarming statistics regarding improper payments and a surge in whistleblower investigations, health systems cannot afford to treat these interventions as routine billing.  

For compliance leaders, the challenge lies in ensuring that every procedure meets stringent medical necessity guidelines before a claim is ever submitted. 

This expert-led blog provides a deep dive into the regulatory trends and enforcement patterns currently shaping the vascular space. It provides technical insights and best practices your team needs to safeguard your organization’s reputation and financial stability. 

Inside this resource: 

• Medicare Compliance Mastery: Understand the specific documentation and coding requirements that federal auditors target in vascular interventions. 
• Fraud Warning Signs: Learn why high volumes in vascular reimbursement are triggering red flags for the OIG and how to stay ahead of these investigations. 
• Recent Investigation Insights: Review lessons learned from recent whistleblower cases that focused specifically on PVD compliance failures. 
• Best Practices for Integrity: Actionable strategies to align clinical documentation with reimbursement guidelines to ensure every claim is defensible. 

Stop letting PVD reimbursement become a vulnerability in your revenue cycle. Read the full blog here to equip your team with the knowledge to navigate this complex environment. 

10. Blog and Tip Sheet – Revenue Cycle Management Compliance: Ensuring Financial Health in Healthcare  

Financial Integrity: Mastering Revenue Cycle Management Compliance 

Revenue Cycle Management (RCM) is the essential financial engine of any healthcare provider, managing everything from claims processing to final payment.  

However, the efficiency of this cycle depends entirely on its alignment with regulatory standards. Without a foundation of strict compliance, even the most streamlined revenue process is at risk of legal repercussions and compromised financial integrity. 

11. Blog and Tip Sheet – Three Strategies to Align Compliance with Revenue Cycle  

Strategic Synergy: Bridging the Gap Between Compliance and Revenue Cycle 

For healthcare organizations, the revenue cycle is the financial lifeblood. However, when compliance and revenue cycle management operate in silos, the resulting friction creates significant regulatory and financial risks.  

To protect the bottom line and ensure long-term sustainability, compliance leaders must lead the charge in aligning these two critical functions. 

Stop letting a lack of alignment become a financial liability. Explore how these three strategies can transform your compliance program into a vital partner for revenue integrity.  

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The post 11 Educational Resources on Revenue Cycle and Healthcare Compliance  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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Download our Latest Whitepaper

Sign-up for our Weekly Newsletter

Schedule a quick overview

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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.