2011 has been rife with government change, and both President Obama and healthcare regulators have been more active than ever in regard to regulatory and healthcare compliance updates and changes.  These new laws and acts, some of which are already in effect, and some of which are expected to go into effect soon will no doubt have a dramatic impact on the industry.  Here is our list of the Top 10 Healthcare Compliance Issues of 2011, we hope you enjoy.

1. The RAC Audit- recovery audit contractors who are independent organizations paid a percentage of recovered fees for providing auditing services are hitting hard across the country.  RAC auditors have the ability to look backward into the history of your organization over 7 years and will scour every nook and cranny of your organization for potential billing and coding errors.  All Healthcare CEOs should be asking themselves how prepared their organization would be for an unannounced audit, or when the last time their organization conducted an internal review of compliance practices.

healthcare compliance

2. Electronic Medical Records (EMRs)- financial incentives for EMRs have been paltry, but penalties for not converting to electronic records will begin to kick in starting in early 2012.  If you add to this the fact that those who have already converted to EMRs are getting penalized for poorly designed software which is not HIPAA Compliant, the case for examining your record keeping methodology becomes even more pivotal in 2011.

3. Speaking of HIPAA- HIPAA violations are another hot compliance issue that organizations should be aware of.  In recent months one organization was fined $2.25 million dollars for failure to properly dispose of protected information, and some physicians have been sentenced to jail time for failing to comply with HIPAA practices.  BHM urges all firms to develop an internal healthcare compliance department, or seek outside consultation to ensure that your organization is not at risk.

4.   The HEAT is on- The governments Health Care Fraud Prevention and Enforcement Action Team, known as “HEAT” is zoning in on healthcare fraud enforcement efforts in an attempt to “reign in fraud, eliminate waste, and get back Americas hard earned money.”  This aggressive team of law enforcement officers, members of the Department of Justice, and the Department of Health and Human Services are all collaborating to bring justice to  any organization or member who is not “in compliance.”  According to the Washington DC based law firm, Liles Parker, this has lead to:

  • Filed charges against more than 800 defendants
  • 583 criminal convictions
  • $2.5 million dollars worth of fines and re-coupment payments

Because the Obama administration has recently requested $60.2 million dollars in funding for HEAT in 2011, many more organization may find themselves in the line of fire.

5. Section 6402 of Health Care Reform Legislation- Yes, we all understand that over payments made to healthcare organizations will be pursued for recovery by the government with all the aggressiveness of a rabid Saint Bernard, but when it comes to understanding the details of what can get you in compliance trouble many physicians may find that they are as susceptible as that kid trapped in the back of the pinto. Section 6402 of the Health Care Reform legislation in particular will be risky for physicians  who will not only need to return any overpayment, but report over payments in writing and explain the reason for overpayment in a justifiable and timely manner.  Just exactly what constitutes timely has not been identified.

6. Medicare Exclusion- How often are you screening your clinical and non-clinical staff members to ensure that they are not excluded from participating in Medicare and other Federal health care programs?  Health and Human Services along with the Office of Inspector General have recently been reviewing care providers, and provider organizations.  Should it be found that a staff member has been excluded from Medicare the organization will be assessed significant financial penalties.  This will remain the case even if the organization screened an individual upon initially hiring them, and if the organization had no knowledge of the exclusion.

7. Independent Auditors (SIUs)- As if RAC Audits were not a great enough threat, organizations which have been found guilty of accepting over payments by RAC Auditors are now beginning to see copycat auditing firms sponsored by Third-Party Payers come in.  Like the second wave of a Tsunami these auditors pick up where RAC left off seeking reimbursement for overpayment from organizations which have already been found to have received over payments.   These new independent auditors are lead by Special Investigative Units (SIUs), and the prevalence of these audits will continue to rise throughout 2011 and 2012.

8. Suspended Payments- payment suspensions by Medicare are sure to increase in the coming months, and are just one more potential threat to an organizations healthcare compliance standing.  Organizations which used to be given advanced notice and warnings if payment was going to be suspended will now see little to no notice of payment suspension actions.  In addition, payments can now be suspended for the smallest of infractions……failing to properly notify Medicare of an address change being one of them.

9. Quality Reporting- The Physician Quality Reporting Initiative, or PQRI, is another change that was ushered in with the new Health Care Reform legislation.  Beginning in March 2011 Physician Quality Reporting went from being voluntary to mandatory, and organizations who are not in compliance with this reporting will be assessed a financial penalty.  Again, ambiguity plays a role in this compliance risk as PQRI data that is required has not been clearly defined at this point.

10. Compliance Programs– 2011 will certainly be the year for beginning, improving, and implementing compliance programs across a broad range of healthcare organizations.  The threats that we highlighted at the top of our list are only some of the  most prevalent and costly, but the total list of compliance risks to an organization could run to hundreds of items.  To make sure that your organization is covered from a compliance perspective please make sure that you have an active compliance program, and if possible a dedicated compliance officer.  If you are not sure where to start consider hiring an outside consulting firm to begin planning and implementing a quality healthcare compliance program for your organization today!

Not Sure where to begin? Call BHM at 1-888-831-1171 for your free Healthcare Compliance consultation