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3 Keys to a Successful Compliance Program

June 13th, 2018 | by Hannah LaMere

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Complying with state and federal rules and regulations is a challenging endeavor. It requires health plans to manage a slew of different processes and resources.  Missteps pose risks that could result in compliance violations, fines and a drop on CMS’s Five Star Quality Ratings.

Some of the most difficult areas to manage, from a compliance standpoint, include staying abreast of CMS updates and other regulatory requirements, producing error-free member marketing materials, and proper investigations management.

To get a handle on these biggest compliance challenges, health plans can start by mastering the three keys to a successful compliance program:

1. Effective collaboration between departments

Health plan departments that operate in silos, lack effective communication or don’t have clear and consistent processes pose a significant compliance risk. In particular, marketing and compliance departments that don’t work together may miss deadlines, experience challenges with document version control or let required updates slip past unnoticed.

All health plans should have a Policies, Procedures and Standard of Conduct guide to help the entire plan get on the same page. This should include:

  • Operational and compliance workflows and policy documents
  • Policies and procedures required by federal regulatory agencies, such as record retention, the government exclusion screening process, and disaster recovery and business continuity
  • Policies and procedures to meet Medicaid contract requirements
  • Code of Ethics and Standard of Conduct documents

Health plans that develop and implement a solid compliance strategy, design, infrastructure and oversight will be best suited to handle any state or federal audit.

2. Solid risk management

A strong risk management program is critical to avoiding compliance violations.

Health plans should be constantly monitoring, auditing and identifying compliance risks. This should include:

  • Compliance programs that focus on risk assessments and ongoing monitoring
  • Compliance audits and CMS mock audits to ensure CMS standards are met
  • Risk assessments and audits to Medicaid contracts
  • Operational department audits to ensure compliance standards are met
  • Delegated vendor audits against contractual requirements

3. Quick, easy tracking and reporting on compliance issues

Federal and state rules and regulations that govern health plans can number in the thousands of pages, with new change-notices being issued weekly. Staying current and ensuring compliance at all levels of an organization can become a virtually impossible task without the right tools.

There are tools that can help health plans manage all rules and regulations in one location for easy access.

For example, The Regulatory Analyzer® by CodySoft® provides a single  location to easily access relevant CMS and state rules and regulations. It can also integrate with the Collateral Management Module® during the process of creating member marketing and provider materials. And, the HPMS Memo Module® allows health plans to streamline HPMS memos by allowing for review, response and automatic updates to the plan’s database.

If your health plan needs help with mastering the three keys to a successful compliance program, contact us today. We have the tools and expertise to take your compliance program to the next level.


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