This article is part of the HHCN+ membership
As providers face reduced margins, compliance-related costs are more concern than ever, but compliance initiatives can lead to additional costs and reduced efficiency.
To improve compliance and prevent loss of additional funds, home and community-based services (HCB) leaders advocate for a change in approach to restructuring compliance as a proactive strategy rather than relying solely on reactive measures. By leveraging technology and addressing all compliance considerations, providers can enhance compliance without incurring significant overhead costs, experts told Home Health News.
“Everyone feels the urgency and pressure surrounding regulatory oversight at every level, from the federal government to states and even managed care organizations,” Haepchange CEO Paul Joiner told Home Health Care News. “They feel the desire for both to remain compliant and to be in a defensive position.”
Founded in 2008, New York-based Hhaexchange is a home care management software company specializing in serving the population of Medicaid HCBS.
The data supports the claim that providers are focusing on lasers when they are compliant. A study by Hhaexchange shows that over 70% of HCBS providers prioritize compliance, with cost reductions and operational efficiency prioritizing. The provider said it faces balanced behavior as it seeks to improve compliance while minimizing overhead and impact on business efficiency.
Compliance is an increasingly prioritized, according to Jnon Griffin, senior vice president at Simitree, but many agency approaches to compliance need to be strengthened to avoid common mistakes. Institutions that lack an appropriate compliance program or rely on government reimbursements that do not comply with health regulations are at risk of facing heavy fines, incarceration, or exclusion from the payer program.
“Most agencies tend to be more reactive than aggressive when it comes to compliance. Unless there is an accredited body that requires us to maintain compliance, we usually don't have a role like a compliance officer,” Griffin told HHCN.
Griffin said that agents may frequently focus on ensuring compliance with oasis and conduct billing audits, but often overlook broader strategic aspects such as participation conditions and HIPAA compliance during normal daily activities.
“Many small agencies lack the talent and staff to do that. They may not have the knowledge, or they may only have been in home care for a few years and may not understand all the nuances,” Griffin said. “We encourage agencies to consider conducting gap analysis because they may not have internally the ability to identify locations that are not meeting regulatory or compliance standards.”
Simitree is a technology-driven consulting platform that serves acute and behavioral health agencies based in Hamden, Connecticut.
While being proactive and ready for audits is extremely important, providers encounter challenges when continuing to train staff, not preparing for audits or not fully leverage their technology partners.
To mitigate the compliance risks of HCBS, agents need to develop strong compliance programs, provide ongoing training, conduct internal audits, and leverage technology for effective management. According to Joiner, key areas of focus include HIPAA, appropriate documentation and caregiver qualifications.
However, compliance involves several steps.
“We are choosing trustworthy technology partners that value compliance and prioritize them, making it a key focus,” Joyner said. “Make sure compliance is integrated, automated and maintained in technology solutions. Prioritize training and awareness and embed it in your company culture. Be prepared for audits.
According to Griffin, appointing a compliance officer is important to establishing a robust compliance program. Executive duties include up-to-date status in evolving compliance laws, developing written policies and procedures, and providing training to employees.
She advised HCBS providers to regularly check the websites of inspectors, the Department of Justice and the National Association to stay up to date on current compliance issues and areas of focus.
“As part of your compliance program, make sure you have best practices and manage your risk,” Griffin said. “No one is risk-free. There are always mistakes, but as many processes as possible are needed to reduce that risk as much as possible.”
By ensuring compliance, organizations acquire programs that provide cost savings, improve quality of care, and promote cohesiveness and transparency in their operations.
Training and transparency
Taking a thoughtful approach to employees and training is a key component of a thorough compliance plan.
According to Griffin, the agency's leadership, including appointed compliance officers, is approachable, so it's essential that staff feel comfortable asking questions and raising concerns about compliance. They should also be confident in learning from these leaders. Employees need training in how, when and how to report suspected non-compliance, using protocols clearly outlined in written plans.
Staff should also be aware where to find this plan and notify you of updates. This training should include all staff, including volunteers and contractors with a focus on HIPAA, patient privacy and data security.
“Compliance training should be part of every orientation at any level. Everyone needs to understand what compliance is,” advised Griffin. “If you see something that is not adhered to, you need to know how to report it. At least every year, training needs must be documented in the HR file. Organizations must have evidence of that training.”
She noted that any compliance issues reported or occurring should be thoroughly adjusted and properly documented to serve as future training resources.
“Documentation is a challenge for home hygiene, and I think it's because of the many different regulatory functions and agencies involved,” Griffin said. “For example, if (the agency) is documenting for surveyors while documenting for claims, it's the best approach to having a strong documentation program that covers both claims and participation requirements compliance.”
Additionally, organizations should ensure that caregivers meet all the qualifications and training they need, Griffin advised. She also recommended that providers clarify financial ties between referral agencies to prevent even suggestions of fraud, comply with anti-kickbacks and self-referencing laws such as the Stark Act, and ensure transparency in all financial transactions, whilst avoiding inappropriate incentives for referrals.
Audit and Technology
According to Alayacare co-founder and CEO Adrian Schauer, all providers are worried about losing their auditors, especially the licenses of the Medicare accredited sector, due to their unified national compliance framework. He described compliance as the “cost of doing business.”
“The long-standing presence of home healthcare institutions on Medicaid side is a mental state, and now they are more susceptible to fraud, waste and abuse,” Schauer told HHCN. “Payers are trying to delve into compliance, and on Medicaid and personal care sides, there is an increasing sensitivity to compliance.”
Founded in 2014, Montreal-based Alayacare is a software platform and secure cloud system that provides clinical documentation, client and family portals, remote patient monitoring, and mobile caregiver capabilities. The company's platform uses artificial intelligence-based prediction models.
HCBS providers should conduct an annual audit to identify and address potential compliance issues. This includes conducting a pre-claim audit to ensure that the request meets pre-submission requirements, Griffin noted.
“It may be beneficial to have an outside auditor review a claim, just as the way government regulators interpret records differently, as it can provide a different perspective compared to someone within the agency,” Griffin explained.
Technologies such as the Electronic Health Record (EHR) system help manage patient data and improve document accuracy. You may also consider using compliance software to facilitate tracking, documenting and reporting, especially if a dedicated compliance officer is not available. Nevertheless, Griffin is opposed to being overreliant on technologies such as AI.
“It certainly helps and makes the process faster, but it should not be replaced by humans,” she pointed out.
For some, technology can help us overcome cost challenges that are becoming increasingly important as margins continue to narrow.
“The margins continue to decline in this industry, and compliance generally adds costs when everyone is trying to cut costs,” explained Schauer. “For software providers, this offers opportunities. If you want to increase compliance without increasing staff or hiring, technology is the solution.”
Schauer recommends that HCBS be in the age of agent AI and automate all agency compliance audits with AI agents, so it is best to continue the process.
“The framework is changing,” he said. “Instead of humans doing occasional audits, AI agents perform ongoing compliance checks.”
When selecting a compliance vendor, agents should ask important questions, Schauer advised.
“In a probabilistic model, you need to ask benchmark questions such as, “Is 70% sufficient? Is 90% acceptable?” And how providers escalate to humans if AI can't make decisions with confidence,” he explained.
Most organizations use cloud-based software, Schauer notes, and cloud providers are responsible for HIPAA and other regulations, providing a trustworthy framework. However, there may be “holes” that can occur, such as unsecured text messages and emails of patient information.
“The biggest threat is not hacking the cloud, but rather phishing employees for their credentials and using them to steal data,” Schauer warned.
It is recommended to implement multifactor authentication and strong passwords to maintain obedient and secure data. If you encounter any issues, we will investigate and resolve them quickly. Establish a transparent reporting process and plan for a data breach or incident.
“Whether you're a small operation or a large organization, you can't ignore this,” Joyner emphasized. “It must be a priority throughout the year with continued attention from leadership and staff. Everyone needs to understand the importance of compliance.”
