Are You Working Toward Strategic Compliance?

ACA, ICD-10, NCQA, HEDIS, STARS, Medicare, Medicaid, prompt payment, quality-based payment programs, clinical guidelines, fraud and abuse, health and wellness programs. Embedded in federal and state legislation, quality and employer mandates, healthcare payer compliance requirements have increased in number, scope and context and now impact virtually all aspects of the healthcare payer business. Healthcare payer CIOs place compliance investments among the top three priorities for 2014.

How effective will these efforts be? What are the emerging best practices?

Compliance in the era of healthcare reform is both an existing business requirement and future state business opportunity. It can be an expensive, inefficient and disjointed last-minute event, or a well-timed, coordinated, integrated effort. It can demonstrate adherence to basic business practices, or be used to demonstrate competitive advantage. It can focus on the present, or set the stage for future business differentiation.

Regardless of whether your organization approaches compliance from a tactical or strategic perspective, there are three new and unique attributes to reform-era healthcare compliance:

  • More than reporting: Compliance now includes activities and processes, and these activities and processes span health plan business units, technologies and programs.
  • A changing bar of performance: Beyond demonstrating adherence to a set standard, compliance now includes a demonstration of improvements over past behavior or outcomes.
  • Volume and future unknowns: The US healthcare community faces unprecedented compliance requirements, and new compliance requirements will undoubtedly continue to emerge.

And, this means the traditional manual compliance reporting approach simply will not work. Finding out that your healthcare organization is out of compliance days, weeks or months after the fact through retrospective reporting puts your organization at undue financial, market and competitive risks. Healthcare organizations need to track compliance in real time and know when compliance risks occur. Furthermore, manual and disconnected processes are too inefficient, cumbersome and risky to be the strategy of choice as compliance mandates proliferate. As compliance requirements intersect and flow across business processes, programs and technologies, it is unreasonable to expect that individual employees will catch compliance issues. You also can’t expect that they will necessarily understand the impact of data, process or technology changes on broader compliance risk. What should health plans look for?

The Technology Response: Ultimately, reform-era compliance is both a reporting effort and a strategy to actively change behaviors and improve outcomes for better business differentiation. In the reform marketplace, healthcare organizations should seek technology solutions to automate and integrate compliance requirements into business processes. This “system-controlled” strategy eliminates potential human error, and ensures consistent compliance interpretation and application at the right time and in the right context. It also provides speed, flexibility and consistency to deal with rapidly emerging or changing compliance requirements. Additionally, integrated activity tracking, documentation, relevant alerts and dashboards enable health plans to actively monitor adherence status, and provide inputs for the immediate response of compliance risks and opportunities for business improvement.

Reflecting the growing list of compliance demands, the new business and technology requirements and the emerging strategic importance, Healthcare payers will spend unprecedented resources on compliance. Will you be positioned to benefit from the speed, flexibility and business positioning that an automated platform will provide?

Granted, that’s a hard question to answer. But if you attend a webinar I’m co-hosting with two of our customers on this very topic, you’ll be better equipped to answer this question – and more.

The Healthcare Compliance Imperative
Hear compliance case studies from Fallon Community Health Plan and Blue Cross Blue Shield Minnesota.