Healthcare Compliance Audits
Compliance Regulations, Accreditation Standards, and Litigation
Healthcare organizations face more regulations from more regulators than ever before. A national managed care organization can be required to comply with over 30,000 separate regulations from both state and federal regulators, and that number grows every year. Even regional or local healthcare organizations, especially managed care organizations ("MCOs"), can be required to comply with thousands of rules. Throw into that mix one, two, or three accrediting bodies, and the typical MCO has quite a management challenge. Finally, add the risk of litigation, and you start to get a sense of how pressing the issue is.
Rising Regulatory Fines, Tougher Accreditation Standards, More Big Lawsuits
To compound matters, the consequence of noncompliance is changing rapidly. Only a few years ago, million-dollar regulatory fines were rare, even unheard-of in some states. Now, they are a regular diet. Accreditation standards and review procedures are tightening up as public scrutiny of accreditation organizations rises. The trial bar as managed care squarely in its sights, and substantial jury verdicts against MCOs are more frequent than ever.
A New Model of Healthcare Compliance Management
No longer with the old-fashioned "legal model" of compliance suffice. A bit of legal advice here, a touch of employee training there will not protect the organization from legal and regulatory risks. Rather, the modern healthcare organization is called upon to integrate its compliance demands -- regulatory, accreditation, and litigation -- into its very structure and operating systems.
Deep Expertise in Healthcare Compliance
At Integral Healthcare Solutions, we understand this world. Our CEO, Tom Goddard, used to work for the insurance regulators, was the Vice President and General Counsel of a large regional health plan, has consulted with and/or audited with dozens of health care organizations, and has served as consultant to the Medicare Payment Advisory Commission.
The Key Starting Point: The Healthcare Compliance Audit
The healthcare compliance audit is one of our most important services. We don't just look at our clients' policies and procedures, we roll up our sleeves and talk to employees throughout the organization. We do this to get a sense not only of how the organization's compliance plan looks on paper, but how it is actually working, and what the organization's "compliance culture" is.
Our healthcare compliance audits include:
- Review of policies and procedures
- Examination of compliance-related information technology
- Interviews of senior executives and front-line employees
- Examination of relevant regulation and accreditation documents, such as Reports of Examination from market conduct surveys of state insurance regulators
- Focus groups (using the modified Delphi process) of employees and executives to help determine risk areas and compliance priorities
- Work with in-house and outside counsel to gain a deep understanding of the legal environment particular to our client
Comprehensive Compliance Audit Report
When we're done with our audit, we write a comprehensive report that our clients can use as a blueprint for moving forward to reduce compliance risk, decrease the staff-time load involved in compliance work, and improve the organization's "culture for compliance".
We encourage you to subscribe to the Integral Healthcare Solutions blog to keep up with healthcare compliance and accreditation developments and interpretations. We also encourage you to pick up the phone and call us with any questions:
Thomas G. Goddard, PhD, JD, CEO of Integral Healthcare Solutions
Tom Goddard
CEO, Integral Healthcare Solutions
(703) 585-9220
tgoddard@integralhs.com