Fail and You Risk Your Practice

In today’s healthcare regulatory climate achieving compliance is not only overwhelming but can also seem like an impossibility. With rules, regulations, policy, and coverage determinations sometimes changing quarterly, healthcare organizations can easily justify a full time compliance officer to navigate the ever-changing landscape but the budget doesn’t always support adding staff. The challenges:

  • reimbursements continue to decline
  • documentation requirements become more and more complex
  • patient load continues to increase

This doesn’t leave many options for healthcare providers. While there are several good manuals and educational resources available the devil is in the implementation detail. Couple these issues with the fact that few medical professionals are skilled (and fewer interested) in: regulatory compliance, interpreting regulations, educating staff or staying current with the constant changes. Where is a happy medium that doesn’t exhaust resources yet will achieve a positive state of compliance for the organization?


First, perfection is not attainable, nor is it required. No one can operate entirely mistake free in an industry that varies to such a degree and inherently requires such a large human contribution. Even with the advanced technology and data analysis employed by the insurance payers they are unable to accurately adjudicate claims 100% of the time. So, if no one gets it right all the time what are the actual expectations? An organization is expected to try. That is to make a concerted effort to be and demonstrate a continual interest in remaining compliant.


Healthcare organizations can put themselves at risk by acting in “willful disregard” of the rules and regulations. By

  • Failing to utilize resources to employ or contract with appropriate personnel,
  • Not committing resources for periodic education and training
  • Not addressing regulatory requirements when implementing new services or products
  • Acting in ignorance of rules and regulations
  • Allowing systemic deficiencies

When deficiencies are systemic it’s not just the occasional billable encounter that that has to be repaid because of a mistake in documentation or a failure to authenticate medical record. Rather every billable encounter that occurs for the organization is at risk because the foundation of operation is faulty.


With thousands of regulations, rules, policies, and contracts how is your organization supposed to avoid all the potential pitfalls and stumbling blocks? Oh, and by the way, I’m sure you’d still like to devote some time and resources to actually seeing patients! How does a health care provider survive, much less thrive? I’ll make some concrete suggestions in my next blog. The following is just a taste of the multitude of published instructions by CMS.


Nick Henson serves as Senior Consultant of Medical Practice Consultantts (MPC).

Nick is an expert at analyzing and evaluating billing and collection statistical information, benchmarking comparisons, and comprehensive operational reviews.  Nick received both his Master's and Bachelor's Degrees from East Central University in Ada, OK.


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