Healthcare Compliance Partner, A&G Vendor or Both?

When health plans want compliance support, and technical solutions that drive healthcare compliance, can they turn to one company to do it all? The short answer is Yes!

Healthcare organizations increasingly need compliance support, given the amount of federal and state regulatory changes they must adapt to on an ongoing basis. While healthcare organizations have Compliance Departments, and operational leaders who review the regulatory changes to decide on what’s applicable for each department, their systems need to be constantly updated to include the latest changes.

This Compliance Department’s responsibilities are significant, but execution does not always roll out perfectly. Issues undoubtedly arise because other priorities grab the attention of the Compliance and operational leaders. However, this is not an industry best practice for healthcare organizations, they simply don’t have a better practice in place, due to no fault of their own.

What the healthcare compliance industry needs is for vendors to do their job and not just to throw more software with “cool” RPA, AI, Machine Learning jargon at their clients. Much more important is for the vendor to do the hard work and become a domain expert in the payer space!

With that said, can a vendor and, in this case, an Appeals & Grievances (A&G) vendor deliver best-in-class technology and healthcare compliance excellence? The answer again is an emphatic Yes! It’s interesting that, more times than not, most A&G vendors are not domain experts in either Compliance or Operations. At the same time, we see healthcare organizations unfortunately choosing vendors who are industry agnostic and need to be spoon fed all that is required for an A&G platform. They need this, not just for Go-Live, but for on-going maintenance of the A&G solution.

Here’s the good news! Today, healthcare organizations have a choice. The days of picking an A&G vendor with no domain expertise in Compliance and/or Operations are over, if chosen properly.The trick is to find A&G vendors who are Compliance partners, as well. And very large national health plans, 5-Star plans and delegated entities are all moving in that direction.

But what exactly is a Compliance partner? There are three primary characteristics of an A&G vendor that also serves as a Compliance partner:

1. Compliance Adherence: Ensure the A&G Solution has a high concentration of Medicare and Medicaid regulatory rules built into the workflows. The A&G “High Compliance” platform should drive compliance throughout the Healthcare Organizations to greater compliance. Here is a list of compliance areas the A&G System should have incorporated:
   • Regulatory Due Dates
   • Invalid Requester Process
   • Quality of Care Grievances
   • Good Cause
   • Case Extension
   • Exigency
   • CMS Categorization
   • MD Expedited Review
   • Appeal Decision Makers
   • MD Decision
   • IRE Package
   • Dismissals & Withdrawals
   • Effectuation
   • Member Correspondence
   • Regulatory Reports, Logs and Universes
2. Proactive System Updates: Ensure the vendor’s Compliance Department stays on top of all the new Medicare and Medicaid regulatory rule changes. It takes the burden off the healthcare organization and rightly puts it squarely on the A&G vendor to stay current with all the regulatory changes. The processes below should be followed by the A&G vendor:
   • Compliance Department reviews all Medicare and Medicaid regulatory changes
   • Compliance Department identifies all relevant changes required to be incorporated within the A&G platform
   • Compliance Department works with the Product Management team to incorporate the compliance changes into the A&G platform at the appropriate time
   • Account Management team ensures the healthcare organization is aware of the changes that have been deployed to their Test Environment
   • Healthcare Organization will notify the A&G vendor’s Account Manager when the release should be pushed into production
3. Compliance Reviews: Ensure the vendor’s Compliance Department works with the healthcare organization’s Compliance Department or Operational Department on any compliance areas they need assistance with, which can even be unrelated to the A&G Department. A&G vendors who invest in compliance domain experts can be leveraged as an extension of an existing healthcare organization’s Compliance Department. There are several differentiating benefits to utilizing an A&G vendor’s Compliance Department for compliance review:
   • They are uniquely familiar with not just CMS or state regulators’ areas of interest, but also offer a unique perspective, since they have a deeper understanding of the intersection of technology and audit findings
   • Their services are priced more favorably than traditional consulting companies
   • Their goal is to set you up for long term self-sustaining success and not looking to stay on your payroll

If you would like an in-depth discussion about our compliance-driven Appeals and Grievances platform, please call us at 1.408.850.2235 or Contact Us.