With the increased scrutiny on Medicare Advantage Organizations (MAOs) in recent news, it’s now more important than ever to have a solid risk adjustment compliance program. Compliance programs are critical in the healthcare industry to ensure that all processes are carried out in accordance with applicable laws, regulations, and ethical standards. With the final ruling on recent Risk Adjustment Data Validation (RADV) repayments and the final
announcement on payment rates for CY2024, now is the time to become laser-focused on compliance.
Build a Team of Compliance Champions
Having compliance champions who understand the rules and regulations that Medicare Advantage plans must adhere to will help inform the correct processes and policies that should be in place. Compliance officers for Medicare Advantage plans should include highly skilled, certified coders and auditors with a deep understanding of CMS guidelines and
regulatory knowledge to comply with external audits. Compliance champions play a pivotal role in ensuring the organization’s adherence to Medicare Advantage regulations and upholding the highest standards of integrity and ethics.
Compliance Champions Ensure a Stronger Compliance Culture
The roles and responsibilities of compliance champions vary between organizations, but
typically they are groups representing different areas and functions who operate as a link between the compliance team and the wider business. These responsibilities are performed in addition to their day-to-day roles.
They receive regular training from the compliance team on how to identify compliance issues and how to help their teams report and mitigate issues that may arise. Champions can help the compliance team take a clear look at what is happening inside the organization at any given time and help identify gaps in knowledge to enable tailored training for different areas. In turn, they can act as ambassadors for the compliance team, spreading messaging to different areas peer-to-peer and in a common language.
There is increasingly a mandate from regulators in many jurisdictions that businesses should have clear processes in place and accountability for how compliance issues are identified,
managed, and escalated throughout the organization.
Typically in large organizations, the approach to incident reporting and accountability for compliance culture can be inconsistent, depending on the business area or function. A dedicated body of champions can significantly improve understanding and engagement with
the company’s compliance program across frontline and mid-level positions.
This increased staff awareness and direct channels of contact between first-line and second-line functions can effectively create an early warning system to proactively understand risk themes across the business. Further, compliance champions can become the drivers and agents of the compliance culture, engaging people across the business to develop and live the desired corporate and ethical behaviors day-to-day.
Annova Expertise in Healthcare
Annova Solutions works with the leading names in healthcare in the US, with a no-
compromise focus on risk adjustment and compliance. With around 20 years of experience, we operate with the highest standards, complying with every regulatory and compliance law. We also place a higher emphasis on accuracy. Accurate coding is essential to ensure proper reimbursement and avoid claim denials. Healthcare providers must implement best practices and technology to optimize Revenue Cycle Management (RCM). With the right coding and billing practices, healthcare organizations can improve their RCM, increase financial stability, and enhance patient care. Accurate coding addresses a host of critical issues, including the right reimbursement, uniform documentation, better patient safety, and significantly reducing the risk of audits and penalties.
Why Compliance Matters
Accurate Payment of Claims
Compliance protocols are essential for the accurate submission of claims, leading to fair
reimbursement for services provided. When healthcare providers follow compliance
guidelines, they ensure that claims are correctly coded and documented, which facilitates
timely and appropriate payments. This accuracy benefits the providers and contributes to
the overall financial health of the healthcare system.
Reduced Billing Mistakes
Billing errors can have costly repercussions for healthcare entities, leading to financial
instability and potential legal issues. By adhering to compliance guidelines, healthcare
providers can minimize billing mistakes, thereby avoiding penalties and ensuring a stable
financial footing. Compliance measures help standardize billing practices, making the
process more efficient and less prone to errors.
Improved Documentation and Coding
Accurate documentation and precise coding are crucial for maintaining high-quality patient
records and ensuring effective communication among healthcare providers. Compliance
practices promote thorough documentation, which supports better patient care by
providing a clear and detailed medical history. Proper coding also ensures that healthcare
providers are accurately reimbursed for the services they deliver, reflecting the true
complexity and scope of patient care.
The Role of Compliance Champions
Compliance champions play an essential role in embedding a culture of compliance within healthcare organizations. These individuals, who come from various departments and functions, serve as a bridge between the compliance team and the broader organization.
They help to communicate compliance issues and solutions in a language that resonates with their peers.
Training and Education
Ongoing training and education are vital to maintaining an effective compliance program. Compliance champions receive continuous training to stay updated on the latest regulations and best practices. They, in turn, train their teams, ensuring that everyone is aware of the compliance requirements and knows how to identify and report potential issues.
Monitoring and Auditing
Regular monitoring and auditing are critical to the success of any compliance program. Compliance champions assist in these efforts by providing valuable insights into their respective areas and helping to identify any compliance gaps. This proactive approach allows organizations to address issues before they escalate, ensuring continuous compliance and reducing the risk of penalties.
Conclusion
In the ever-evolving landscape of Medicare Advantage, compliance is more important than ever. With increased scrutiny and new regulations, having a robust compliance program is essential. Annova Solutions is at the forefront of compliance in healthcare, offering expertise, training, and support to ensure that healthcare organizations can navigate these complexities effectively. By building a team of compliance champions and fostering a culture of compliance, healthcare providers can improve their operations, enhance patient care, and maintain financial stability.