An unlikely candidate for pandemic-triggered innovation: Compliance monitoring

In the last year, the pace of change for healthcare organizations has seemed to accelerate dramatically. When the industry that has been famously slow to adapt was suddenly upended, old attitudes about technology and innovation were turned on their heads. As large-scale trends like telehealth and value-based arrangements affect care delivery and utilization, making sure clinicians have the valid credentials and statuses to deliver care is becoming more important—and complex—than ever. 

How is the growing pressure for automation in healthcare administration propelling compliance monitoring forward? 

The goal of compliance monitoring and data verification is to reduce risk and protect patients through ongoing insight into a provider’s status with various primary data sources. But compliance screening workflows have typically not kept up with technological advances, leading to cumbersome processes that hold organizations back and present unnecessary risk. 

Many health systems, providers and payers are finding themselves still managing disparate processes for ruling out OIG exclusions, validating NPIs, verifying licenses, and other often-manual compliance screening tasks, wasting time and resources. Compliance monitoring programs are poised for increased automation because scaling old models is unsustainable, and, when given the right data, algorithms can effectively manage the vast majority of tasks.

The actions of compliance authorities can impact the risk of ineligible providers within your organization. Oversight agencies are not only detecting fraud, but they are also prosecuting and assessing administrative violations. If you have a sanctioned provider working for or billing through your organization it is more likely than ever that an oversight agency will find them, even if you don’t. 

OIG exclusions represent a large and critical segment of compliance screening. While OIG allowed for discretion during public health emergencies, the agency did not stop levying exclusions. In 2020, the OIG excluded a total of 2,378 individuals and entities (down slightly from 2019), while reinstating a total of 546 individuals and entities. 

Throughout 2020, the total penalties levied by the OIG for exclusions and licensure issues was $1.57 million for 17 individuals, equating to more than $92k per individual.

As state emergency declarations rolled across the country, healthcare licensure requirements were relaxed to allow clinicians to respond to the most dire situations. Disciplinary actions against licenses in 2020 also slowed to a trickle. More than a year later, organizations are still navigating a patchwork of requirements including temporary and emergency licenses, extended expirations and a variety of waivers. This requires onboarding, credentialing and verification processes to continuously adapt to varying - and changing - standards across states, which is a difficult task.

Typically, compliance monitoring has been seen as a necessary expense, not unlike an insurance policy. While avoiding costly and troublesome civil monetary penalties is important, faster, more flexible solutions are powering teams and workflows across healthcare organizations. Whether the population is employed clinicians, contracted providers, or a variety of downstream and related entities, instant and ongoing insights into identity and credentials can support workflows from hiring and contracting to scheduling and processing claims. 

The compliance monitoring programs of the future will combine sophisticated automation and integrations with efficient human oversight to leverage results within critical business workflows. The healthcare populations that provider and payer organizations rely on are only becoming more complex, with responsibility for oversight distributed across multiple teams. 

Though compliance officers and teams may still be ultimately responsible for compliance monitoring and data verification, the number of stakeholders at the table has increased dramatically, from operations and HR to IT/security and finance. As more teams apply pressure to monitoring programs, these solutions must combine advanced security and integrations with real-time data verification and a flexible platform to support faster decision making and minimize unnecessary work. 

While the shifts to remote work and care have generated new reasons for smarter processes, the core challenges remain. These are the critical challenges that smart, adaptive compliance monitoring must overcome to deliver measurable business value: 

• The available data is still sparse, making it difficult even for sophisticated technology to return exact-match results. 
• License boards report statuses with significant variance, often requiring manual oversight and verification. 
• It is easy to miss—and hard to catch—bad actors who change their name and location. 

ProviderTrust has engineered the industry’s smartest compliance monitoring platform, delivering always-accurate exact match results and audit-ready documentation through real-time integrations. Learn more about how this space is adapting in our Compliance Monitoring Trend Report. 
 

Donna Thiel is the Chief Compliance Officer of ProviderTrust. With 30+ years experience in long-term care, Donna leads the vision, execution, and strategy of our compliance vertical and operation, in addition to heading up our Corporate Integrity Division. She is an active speaker on compliance strategy and industry thought leader.
 

Founded in 2010 with a vision to simplify healthcare compliance, ProviderTrust has grown into a leading healthcare data and technology company serving the nation’s top health systems, payers, and pharmacy organizations. ProviderTrust monitors millions of data records to identify license, credential, compliance, and payment eligibility issues before they impact patients.