Healthcare Regulation Compliance​

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Today’s healthcare is the most regulated industry in the country and boasts increased scrutiny of corporate conduct and increasingly large expenditures for health care, therefore, it is imperative for health care providers to establish and maintain an effective compliance program. This program should foster a culture of compliance and a commitment to the delivery of quality health care.

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Obviously, the best reason to have a compliance program is to prevent violations of the law. In recent years health care organizations have been hit with enormous fines and health care managers and executives have faced lengthy prison terms. Health care organizations that violate the law can be debarred and excluded from further participation in Medicare, Medicaid and other government programs.

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With the passage of the Patient Protection and Affordable Care Act of 2010 (PPACA), physicians and other health care providers who treat Medicare and Medicaid beneficiaries will now be required to establish a compliance program.

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A healthcare organization may receive a 70% – 95% reduction in fines and penalties. Even though, they have committed a violation of the law, IF an effective compliance program is in place. A major part of any provider practice’s compliance program is the identification of risk areas associated with coding and billing.

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Health and Human Services (HHS), Office of Inspector General (OIG), Centers for Medicare and Medicaid (CMS) and by the Health Care Fraud Prevention and Enforcement Action Team (HEAT) are all going to mandate all health care providers to establish a compliance program in the near future.

Healthcare Regulation Requires all entities (e.g. Providers, Payers, hospitals and other participating agencies) operating or interacting in the healthcare market to comply with HIPAA, 5010, ICD-10 and Meaningful Use (for providers). Compliance to these specific regulations and standards require significant efforts at all level across organization and touch almost every aspect of the healthcare provider business.

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