Use a compliance work plan to build a pattern of revenue integrity success

Compliance is woven throughout the fabric of revenue integrity. Without the guidance and expertise of compliance, revenue can’t be considered truly accurate and audit-proof. By using a compliance work plan to weave compliance best practices and audit findings into revenue integrity, organizations can flip revenue integrity processes from reactive to proactive.

Carol Waughen, director of compliance, at Evangelical Community Hospital in Lewisburg, Pennsylvania, knew her organization needed to stay ahead of external auditors, monitor internal risks, and track compliance and improvement activities. These priorities only grew more complex and pressing as her organization expanded to include newly acquired physician practices. When Waughen’s role shifted to also include overseeing compliance for the growing physician practice side of the organization, she took the opportunity to establish a formal compliance work plan that spans the entire organization.

The compliance work plan is based on risks identified by CMS and the Office of Inspector General along with risks found in the organization’s own internal and external audits. Waughen established a compliance work plan committee that meets monthly to identify, analyze, and prioritize those items and determine the level and type of risk each one represents to the organization. The risks might be monetary, legal, regulatory, or reputational. Waughen runs the committee and weighs in on the organization’s compliance responsibilities. The committee includes members from the revenue cycle department, such as coding and billing compliance, patient financial services, patient access, CDI, and health information services. Waughen says that these members are vital to the success of the work plan process.

“I have the input from a compliance side on what we need to do. How do we take care of this risk? What do we do to put something in place? I may not carry out those actions, but I ensure that those actions are put into place and that something is being done,” Waughen says. “We develop action plans on our identified risks and we keep those action plans on the agenda until they have been resolved.  As part of the action plan we audit and monitor to ensure processes are being followed and procedures are working as intended in order to mitigate the risk.”

Internal audits, whether carried out by the organization’s staff members or a third-party, provide data critical to keeping ahead of a variety of problems. For example, an internal audit might reveal the organization needs to look more closely at billing incident to services, Waughen says. “We would then perform an audit to ensure that we are doing this correctly. If we find an issue, we would enter this on our work plan and develop an action plan to fully review our processes and procedures and implement changes necessary to ensure compliance with regulations,” she explains.

If a coding and billing error that resulted in an overpayment is identified, the organization follows procedures for reporting overpayments and resubmit all affected claims for proper payment.

One of the most critical steps in the work plan process is the creation of the corrective action plan. The compliance department and the departments involved in the error implement and monitored to ensure the issue does not reoccur.

It’s not just coding and billing that should be monitored, Waughen cautions. Running afoul of any regulation can hurt revenue integrity. She points to recent regulation on hepatitis C testing for which Evangelical Community Hospital set up the required forms and documentation options in its EHR, then ran audit reports to show compliance with the regulation. If the new process is not followed, the organization could face a regulatory risk that can lead to revenue loss, she says.

The compliance work plan has allowed Waughen and her team to start looking to the future rather than struggling to patch up past mistakes. “We’re trying to become more proactive than reactive. We’re really trying to look at things when they come in, new regulations or new codes. Not waiting to find an issue, but proactively looking to make sure we are doing it correctly,” she says. “We’re trying to make process changes to do what we should be doing rather than waiting until a problem comes up and then reacting to it.”