Provider Compliance Services

Provider Compliance Services

Opportunity

Providers have an opportunity to proactively display their commitment to compliance and minimize the risk or impact of regulatory reviews by government agencies. Effective auditing of the compliance program adds to existing compliance efforts and offers assurances that providers are operating in accordance with state and federal regulatory requirements and standards.

Insight

Healthcare providers are subject to extensive regulatory scrutiny. Government enforcement of state and federal regulations has been increasing in recent years, resulting in a greater need for robust compliance processes. Government action has included agency fines and sanctions as well as criminal and civil prosecution. Failure to address the risks properly can result in civil and criminal penalties and significant damage to an organization’s reputation.

Management needs to be proactive about addressing these issues. Responses include developing and implementing entity-wide compliance programs. Protiviti has developed a seven-step methodology for managing the compliance function based on the seven-step guidance from the Federal Sentencing Commission and the Health and Human Services Office of the Inspector General, as well as industry practice.

Impact

Services

  • Compliance program analysis and implementation
  • Physician contract review (financial and compliance assessment)
  • Clinical research audits – financial and compliance
  • HIPAA privacy review
  • HIPAA security audit
  • CIA medical review organization services
  • Compliance program effectiveness review
  • Coding and medical necessity audits Medicare appeal assistance

Benefits

  • Increased confidence in, and management of, regulatory compliance efforts
  • Clear understanding of regulatory risks
  • Insight into regulatory compliance
  • Proactive display of compliance risk monitoring

Outcomes

  • Development of control action plan for provider and affiliates
  • Repeatable and measurable audit process
  • Identification of compliance control improvements

To assess regulatory risks and operating state, Protiviti uses the Six Elements of Infrastructure for assessing and reporting risks.

Protiviti uses the Capability Maturity Continuum to measure a provider’s maturity and assists in its progress from the initial/ad-hoc stage toward the optimized state.

Contacts

If you would like to learn more about our Provider Compliance Solutions or contact one of our practice leaders, please visit www.protiviti.com/healthcare or call 866.721.8340

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