Panting and sweating, I kept running from a menacing dark shadow following me. I ran faster. My heart beat spiked as I heard my name, followed by the words – ‘Wake up’! Phew! It was just a bad dream.

While sharing this with my friend (Compliance manager at a Health Plan), I asked him, “What’s your dreaded nightmare?” His reply, “The mere thought that my organization doesn’t conform to regulations and it would affect our star ratings.” We laughed it off. But, could this be a reality ?

Compliance has always featured among top priorities for Health Plans. And, it’s certainly even more top of mind since the U.S government suspended new enrollments in a large Medicare Plan’s health insurance and prescription drug plans due to operational deficiencies.

This gets me thinking – What’s a health Plan’s compliance strategy?

The game of rules

As a Healthcare organization, it’s important for you to know how the information is being transmitted and stored in your systems. Is it being managed in accordance with regulations ?

To help Health Plans play by the rules, here’s a quick checklist (outlined by the Office of Inspector General of the department of HHS) for your compliance program:

  • Written policies, procedures and code of conduct – Foster a compliant environment and articulate and demonstrate your commitment towards compliance. Also, let employees know what action needs to be taken and when based on the written guidelines.
  • Compliance officer or Compliance committee – Maintain an oversight and keep a check on all your processes with a designated officer or a compliance steering committee. Identify, prevent and resolve cases violating any rules laws and regulations pro-actively.
  • Training and Education – With myriad of rules and regulations to comply with, train your employees for what they are up against.
  • Communicating effectively – Collaboration and effective communication across organization in the event of any violation, amendments to your compliance strategy or to Federal or State laws and regulations is the key.
  • Well-publicized disciplinary guidelines – After receiving a violation case, a layout for further proceedings – suggesting an action plan for sanctioned employees, aids in decision making.
  • Monitoring and audit – Internal audits results in diagnosing problems at an earlier stage followed by corrective measures
  • Prompt action and reporting – Time is of the essence in such cases and faster actions are demanded to correct the identified problem areas

Which card to bet on?

For Health Plans, secured information distribution and disclosure, timely records retrieval, efficient processes and accurate information is the key to compliance. We can devise a fool-proof strategy based on the above checklist but what about systems being used ? Since healthcare organizations are held to the highest standards of data security their systems also need to ensure the same.

With this let me introduce BPM – a card to bet on.

A BPM solution offers Health Plans a host of benefits :

  • Optimized processes – Reduce manual hand-offs by automating and transforming processes which further reduces scope for errors
  • Better patient care – Integrate BPM with other information systems to access real-time information, reduce processing time and enable faster decision making, resulting, in better patient care.
  • Secured information – Helps clearly define roles and responsibilities for business users and assigns rights-based access
  • Easy integration capabilities – With capability to comply with global standards and easy integration abilities, leverage and consolidate your existing IT infrastructure

With the checklist and a reliable platform to streamline processes, the tricky part of managing a mammoth of information remains.

It takes two to tango!

To notch up the game plan, what we need is an ECM system in tandem with a robust BPM. An Enterprise Content Management Software (ECM) allows end-to-end management of your enterprise content like member medical records, allowing its secured archival and retrieval as per regulations.

By leveraging BPM to transform processes and ECM’s ability to connect clinical, administrative and back-office, you can witness the transformational journey of your healthcare organization.

Do away with nightmares

Integrating BPM and ECM with your core systems can serve as a trump card in your compliance strategy. So, to have a card up your sleeve, BPM and ECM is what you would need for optimizing patient services and complying with a myriad of regulations.

So, it’s time to strategize and play cards right.