Creating a Stronger Billing Compliance Program

Health care is no stranger to rapid change. Over the past few years, health care leaders have been navigating new payment models, increased consolidation activities and the rise of consumerism. As such, these areas demand constant attention from a compliance and strategic standpoint. Due to the complexity involved in adhering to the regulatory standards of these high-risk environments, it’s important to understand how your organization’s technology and data analytics bolster your monitoring and tracking of critical compliance protocols.

Health care fraud and compliance violations are usually hidden in the details. As proof the Office of Inspector General (OIG) is aggressively pursuing compliance and potential fraudulent activities, try to find a week without an OIG settlement headline. Recently, these monetary settlements have ranged from $500,000 to $42 million, with ongoing oversight from various regulatory agencies. Moreover, the financial and operational challenges related to these settlements have been significant.

In addition, health care leaders should understand how the OIG pursues, profiles and targets compliance issues. This article is meant to be a resource to help health care leaders proactively mitigate compliance challenges for their organizations and avoid becoming the next headline.

How is the OIG identifying fraud?

It’s using analytics to identify irregular patterns. With electronic health records becoming more sophisticated, building strategic analytics has become easier. The good news is analytics can and should work in your favor—and you’re capable of leveraging your own analytics for the same purpose to stay a step ahead. 

What’s changed with the OIG work plan?

Prior to June 15, 2017, the OIG was updating the work plan annually—but today, it’s updating this site monthly. It’s assessing U.S. Department of Health & Human Services programs and operations, while focusing on the areas deemed as highest risk. If your organization is still reviewing the work plan annually, it’s critical to begin reviewing the work plan on a monthly basis and developing ongoing action plans.

Who else is ramping up compliance efforts?

We’re seeing increased efforts by Medicare Administrative Contractors, Recovery Audit Contractors (RAC) and Zone Program Integrity Contractors—and sometimes these organizations coordinate with each other and with the OIG. All RACs have websites disclosing the issues they’ll be monitoring, so it’s important to bookmark their website and give it regular attention.

Developing relevant data analytics to monitor compliance protocols and mitigate risks around these complex issues won’t be a small task. As a result, we encourage our clients to take an enterprisewide approach with a team comprising key resources from compliance, finance, health information management, billing and IT. This team needs to develop an integrated compliance and data analytics strategy that identifies compliance challenges (in real time). The initial development and creation of these data analytics are part art and part science, but it’s a necessary organizational investment.

Because billing challenges frequently are the root cause of compliance violations and fraudulent activities, our revenue cycle team has created a detailed guide to assist health care leaders. Download the guide on our revenue cycle page and contact your trusted BKD advisor if you have questions.