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Foundations of Compliance: Creating a Compliance Framework through Screening, Verification and Continuous Monitoring

May 9, 2019

Compliance best practices are designed to ensure quality of care and patient safety, as well as to minimize risk to your organization. Benefits of compliance adherence include avoidance of fraud, waste, abuse, penalties, fines and possibly exclusion.

A compliance-driven culture is created when all levels within an organization understand and enforce the compliance policies and procedures.

To fully understand the “begin with the end in mind,” philosophy of compliance, it is important to consider the following three levels of a compliance program: State and Federal Regulations; Standards for Accreditation and Certification; and Best Practices that customize and exceed guidelines set by the government and standard-setting organizations.

State and Federal Regulations – This is what we term the, “Have To” level.  Non-compliance on this level could result in fines, penalties and exclusion from participation in State and Federal reimbursement programs.

Mandatory exclusion from all Federal health care programs occurs if an individual or entity engages in any of the following according to the Health and Human Services (HHS) Office of the Inspector General (OIG): “Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs; patient abuse or neglect; felony convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.”

Mandatory exclusions are on the felony level and typically last five years each. A formal reinstatement must take place before restoring the ability to participate in State and Federal programs. After three mandatory exclusions, the provider or entity is permanently excluded.

Permissive exclusions are misdemeanor offenses and exclusion is at the discretion of the HHS OIG.

There is often a lag time between the initiation of an internal investigation and what might result in a conviction and subsequent exclusion. This gap opens an organization to risk. To close the gap, thorough initial screening, followed by continuous monitoring using Verisys’ proprietary data set FACIS®, Fraud Abuse Control Information System, will reveal adverse behavior in real time. FACIS® checks for sanctions, disciplinary actions, exclusions, board minutes, arrests, and taps additional sources of data records that can indicate red flags that provide actionable information to prevent or manage ongoing association with a high-risk provider or entity.

Standards Setting Organizations – This is what we term the, “Choose To” level. Holding certifications and accreditations represents a committed alignment with industry recognized standards of quality and processes.

Some examples of programs based on quality include the Centers for Medicare and Medicaid (CMS), Healthcare Effectiveness Data and Information Set (HEDIS), Sustainability Tracking Assessment & Rating System (STARS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), The Joint Commission (TJC), the National Committee for Quality Assurance (NCQA), Det Norske Veritas (DNV GL), Utilization Review Accreditation Commission (URAC), National Patient Safety Foundation, Institute for Healthcare Improvement, and dozens of others.

Several standards influence or even directly determine the amount of reimbursement, as they are tied to quality measures.

Verisys is URAC accredited and NCQA certified for 11 out of 11 credentials verification services, and also holds two ISO certifications, 27001 and 9001. CheckMedic®, Verisys’ SaaS platform that accesses FACIS® along with some 5,000 additional primary sources, tracks and assures compliance to recognized standards by checking against the most current requirement criteria. Having this level of automation and precision, adherence to the most recognized industry standards does not add additional administrative burden on the medical staff services, compliance or human resources departments.

Best Practices – This is what we term, “Desire for Excellence”. Adding an additional layer of policies and procedures that envelop and exceed the standard requirements, sets your organization apart from the rest. By taking a proactive and holistic approach to compliance, you are able to stay ahead of the curve with policies and procedures that focus on the core purposes of compliance: patient safety and risk mitigation.

Verisys’ mission is to provide the blueprint and an engine of automated compliance tools comprised of comprehensive data, an integrated platform with customization, and methodology to activate a turnkey execution of excellence throughout an entire enterprise.

Call for a consultation and we will pinpoint your areas of risk and follow up with a full-concept solution to bridge the gaps, set you ahead of the curve, and put you on the trajectory of compliance, economization and automation.