Five Areas of Compliance Medical Practices Should Watch in 2014

It’s a new year and there are five key items providers should follow in 2014:

1. The Sustainable Growth Rate (SGR) Formula. Building on various bills that were presented in both the House of Representatives and Senate in 2013, further legislation will be considered by Congress to permanently repeal the SGR, which was created by the Balanced Budget Act of 1997 (Pub. L.105-33, Sec. 4502 (Aug. 5, 1997)). The outcome can impact the revenue cycle because it impacts Medicare payments for physician services.

2. HIPAA and HITECH Act Compliance. With the Omnibus Final Rule becoming effective on Sept. 23, 2013, which includes greater penalties for non-compliance, all entities transmitting, creating, receiving, or maintaining protected health information need to make sure they are compliant. This includes obtaining reasonable assurances from business associates and due diligence to make sure that the business associates have obtained reasonable assurances from their subcontractors. Failing to do so can result in civil and criminal fines on both a state and federal level.

3. Meaningful Use. Compliance is just around the corner and all entities that are either transitioning to an EHR or currently utilizing such systems need to make sure that the standards are being met and that ongoing monitoring is in place. Two areas of great liability are "cut and paste" policies and procedures and over documentation-adding unnecessary and irrelevant items into a medical record to "bolster" the record. These two areas of non-compliance open the flood gates to fraud, breaches, and penalties.

4. ICD-10 Implementation. If your office has not done so, it is time to start the training and transition process from ICD-9 to ICD-10, which becomes effective Oct. 1, 2014. Specifically, training, proper technology to handle the increase in the number of codes in billing, and medical necessity standards should all be identified. A good way to approach this is from an enterprise risk management perspective with an emphasis on patient care and the revenue cycle.

5. Health Insurance. With the Affordable Care Act mandates for health insurance becoming effective, providers should stay abreast of changes and reference the CMS website, as well as coordinating with various insurance companies. Many patients' plans will be changing and this can cause a bottleneck in billing flow, which can impact the revenue cycle. Since many may be switching from a PPO to an HMO, prior authorization or referrals may be required. To avoid payment rejections and slower work flow processes, be proactive.

In sum, there are a number of changes that providers need to be aware of. Keeping abreast of policies and utilizing external experts to assess process and implement requisite policies, procedures, and standards can minimize adverse impact to a practice. Use these changes to be proactive and to be positive. With the right implementation, greater efficiencies can be realized.