Helping you to understand the healthcare revenue industry in the simplest terms.
You might be vaguely familiar with healthcare compliance, but chances are you don’t understand why it’s so important, or how it came to be. Healthcare compliance can honestly be really complicated. It changes often, leaving hospitals to scramble to make sure they’re still in compliance to avoid lawsuits.
We’re going to explore what it all means, and what’s most important to know.
What does healthcare compliance even mean?
Even if you have a general idea, we’re going to get into the weeds so you’re fully informed by the end of this article.
Basic overview
Here’s the easiest way to explain healthcare compliance: it is everything a healthcare organization does to make sure they are following all the rules and regulations in their particular facility.
The rules and regulations come from national and state laws, general industry standards, as well as contracts they keep.
While it can be overly stressful for an organization to keep their operations within compliance across all the rules and regulations, it’s actually one of the best ways they can stay competitive in the industry.
How does it work in healthcare?
Any healthcare organization is so much more attractive to potential clients if they can confidently say they are in compliance. It means, to their clients, that they are dedicated to following the rules and keeping everyone safe.
Most of the rules and regulations deal with patient safety and data security, as well as reimbursement and insurance policies. All of these, while they can quickly add up, mean that the patient is being highly considered and cared for.
What are some ways healthcare compliance works?
If a healthcare organization does not remain in compliance, one of the most common ways that the organization will be held accountable is through lawsuits. These lawsuits are often extremely expensive and labor-intensive.
Other consequences include fines and even criminal charges.
It is in the best interest of everybody — from the organization to the patient – to remain in compliance to keep everyone safe.
Main pillars of compliance
We briefly mentioned the types of rules that are in place for organizations to comply with, but there are three major categories they fall into: patient safety, patient and data privacy, and billing and coding.
Patient safety
Patient safety regulations deal strictly with patient care. These are things like standardized protocols and accurate record keeping. With standardized protocols, healthcare professionals are much less likely to make mistakes during any given procedure. With accurate and consistent record keeping, professionals are less likely to make dangerous mistakes with medications and prescriptions, among other things.
Patient and data privacy
This is one of the biggest sectors of compliance. Patient security and data privacy are essential to a compliant healthcare organization; it helps to prevent fraud and abuse, it protects the patient’s identity, and it ensures that every party involved can make informed choices about their data and health.
Billing and coding
This area of compliance revolves mainly around accurate billing to patients and insurance companies, and using the correct coding systems for insurance as well. These practices help to prevent fraud and increase the efficiency of the system.
Three common healthcare laws
We’ve chosen three of the most common healthcare regulations to explain. Keep an eye out for more in-depth articles about each of these, but you’re probably familiar with them, at least by name.
We’re going to dive into how these regulations work, and why you should care about them.
No Surprises Act
In 2021, the U.S. passed legal requirements to protect patients against surprise bills. These surprise bills can hugely impact a patient, especially if they are not able to pay the bill.
How does it work?
The act offers multiple protections, including establishing a process to calculate payment amounts, requiring good-faith estimates of services and items, establishing a dispute resolution process for uninsured patients, and creating a pathway to appeal certain decisions.
Why does it matter?
While this might look like a lot more work for providers and facilities, this act was one of the most significant moves to establish more trust and security in the healthcare industry.
Health Insurance Portability and Accountability Act (HIPAA)
HIPAA is a widely-known federal act, but how much do you really know about how it works?
How does it work?
HIPAA ultimately gives patients rights over their health information. It gives them the opportunity to set rules and limits around who can access their health data, and it protects their information across all forms – electronic, written and oral.
Why does it matter?
This means that providers and facilities must practice extra caution when accessing and sharing patient data. This also applies to third party companies. The act was introduced almost 30 years ago, so most facilities are well-aware of its terms.
Affordable Care Act (ACA)
The ACA was enacted relatively recently in 2010, and it has impacted healthcare facilities and insurance policies nationwide.
How does it work?
The ACA reformed comprehensive health care. It made health insurance more affordable and available to more people by offering subsidized tax credits. It also expanded Medicaid and encouraged innovating medical care delivery methods, all in the name of lowering costs.
Why does it matter?
This act is meant to support lower income patients, allowing them to access health care that was previously too expensive. This means that more people are coming into facilities with insurance, and healthcare professionals are interfacing more with insurance companies.
Final thoughts
We hope you found this article useful. We’re working on so many more education-focused articles for you to enjoy; be sure to keep an eye out for more soon!
Check out our website for more important information about compliance and regulations.
If you’re part of a healthcare organization, and you’re completely overwhelmed with compliance and don’t know where to start, we can help. Just head to our website now to chat with one of our compliance experts to learn more.