Published on 06 June 2011
Compliance Challenges of Health Reform: Questions Compliance Professionals Should Ask as They Prepare for Health Care Reform

With an array of payment reforms, quality and safety requirements, massive expansion of Medicaid, and creation of the new State Health Benefit Exchange marketplace, the Affordable Care Act (ACA) presents extraordinary new challenges for compliance, especially for health plans, physicians, hospitals and health systems, and drug and device manufacturers.

In a recent keynote address at Health Care Compliance Association’s Annual Compliance Institute, Daniel R. Levinson, Inspector General for the Department of Health and Human Services (HHS) outlined some key questions every compliance professional should ask as they prepare for health care reform.  Here’s an excerpt from the OIG:

Transparency: Are you prepared to operate in a more transparent health care system?

  • Does your organization have the right systems and technologies to meet new demands to collect, organize, track, retain, and report information and data accurately and completely?
  • Do you have security and privacy protections in place for creating, transmitting, and storing data?
  • Do you have systems in place to meet enhanced reporting and disclosure requirements applicable to your industry segment?

Quality: Are you focused on quality as a compliance issue?

  • Do your clinicians understand that quality is a compliance concern and that quality of care is increasingly integral to payment?
  • Do you have systems that will ensure that charting, collection and reporting of quality data and clinical documentation are accurate, complete, and sufficient to justify payment?
  • Are you present during conversations and involved in decisions about quality in your organization?
  • Does your compliance department have the expertise to address quality-related compliance issues?
  • Are your board of directors and management informed about the heightened role of quality of care under health care reform?

Accountability: Is your organization prepared for greater accountability?

  • Do you have a compliance plan in place? If not, is your organization prepared to create and implement one?
  • Do you know with whom your organization does business? For example:
    • Does your organization have affiliations with excluded, suspended, or Medicare debt-owing individuals and entities?
    • Are you prepared to meet new requirements for background and licensure checks?
    • Are the persons furnishing services through your organization qualified to do so?
  • Are you focused on identifying and addressing new fraud and abuse risk areas that may arise as your organization becomes involved with new payment and delivery systems (such as medical homes, accountable care organizations, bundled payments, and value-based purchasing)?  For example:
    • Are you thinking about risk areas such as inappropriate stinting on care, “cherry picking” patients, “lemon dropping” patients, gaming of payment windows, and misreporting of quality or performance data?
    • Will you have safeguards in place to address these and other risks?
    • Will compliance be part of the conversation as your organization contemplates new business and reimbursement arrangements?
  • Is your organization addressing its increased compliance and quality responsibilities under health care reform?  For example:
    • Are managers, staff, and contractors aware of their responsibilities?
    • Are your training systems robust enough to support a new learning curve?
  • If you represent a private insurer or employer organization preparing to participate in new public programs (e.g., participating in the State Health Benefit Exchanges or in the temporary employer retiree reinsurance program), does your organization have systems in place to ensure compliance with applicable program requirements?
  • Do you have systems in place to screen for improper claims before they are filed?
  • Are you using data mining and other techniques and technologies to detect improper claims?

About Author

An expert on Medicaid, Medicare, and health reform, Kip Piper, MA, FACHE, is a consultant, speaker, and author. Kip Piper advises health plans, hospitals and health systems, states, and pharma, biotech, medical device, HIT, and investment firms. With 30 years’ experience, Kip is a senior consultant with Sellers Dorsey, top specialists in Medicaid and health reform. He is also a senior advisor with Fleishman-Hillard and TogoRun. For more, visit KipPiper.com. Follow on Twitter @KipPiper, Google +, Facebook and connect on LinkedIn.

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