Medical billing industry has volumes of arcane terminology and payer- and time-dependent claim validity and pricing interpretation rules, facilitating massive payments of invalid or ineligible claims and denials of error-free claims. Process transparency provides its participants greater visibility of internal process activities. An increased level of access promotes teamwork, increases client satisfaction, and assists in process streamlining.
Billing process is the interaction between the participants (i.e., insurance company (payer), healthcare service provider (provider or doctor), patient, and billing service provider (biller)) designed to pay or deny a payment request (claim) submitted by the biller to the payer and to the patient on behalf of the provider. The amount and complexity of billing information make it very difficult for the doctor to maintain compliance and identify and resolve errors and underpayments.
Billing service transparency allows participants of the billing process to expedite error identification and resolution, resulting in reduced over- and under-payments and improved regulatory compliance.
Attributes of Billing Transparency
Billing transparency has four key attributes, including universality, continuity, ubiquity, and scalability.
Universality: every participant in the billing process, including patient, provider, payer, and biller, has access to every aspect of the billing process.
Continuity: process detail is available continuously on a 24 x 7 basis.
Ubiquity: access to billing process is provided over secure standard Internet browser that requires no special hardware or software and is available everywhere.
Scalability: both the big picture and minute detail are available for scrutiny universally and continuously. The big picture consists of total cash flow in a given time period, current submitted and failed claims, and billing quality metric. It must contain comprehensive summary of patient visits and unpaid balances. The minute detail pertains to individual claims making up the big picture, including complete history from the moment of creating the claim, testing its validity and eligibility, making corrections, performing submissions, reconciling payer messages and explanations of benefits (EOB) with original claims, until payment. Both perspectives must allow arbitrary aggregation of claims and drill in for detail to enable effective followup.
How to Build Transparency Into Your Billing Service?
A transparent billing service leverages technology to enable competent personnel to execute disciplined billing process. Therefore, to implement a transparent billing process, you must
[ ] Get access to adequate technology to support universality, continuity, ubiquity, and scalability.
[ ] Develop and thoroughly document claim processing procedures, including compliance and integration with practice workflow.
[ ] Train personnel in following the procedures and using the technology
[ ] Review personally and continuously billing quality, technology capabilities, adequacy of procedures, discipline, and training.
Note that Vericle-like technologies based on Straight Through Billing (STB) methodology implement billing transparency by design because billing transparency is an integral attribute of every component of STB process.
Senin, 20 November 2017
Jumat, 13 Oktober 2017
Required Filings for Charitable Solicitation Registration - Renewal and Compliance
Attorneys, paralegals and compliance officers with a strong corporate focus that are providing services mostly to for-profit clients often find that state nonprofit compliance requirements can be challenging and confusing. In addition to dealing with annual state nonprofit corporate compliance, there is a second component to state nonprofit compliance - the annual charitable solicitation registration. While some of the jargon and form names associated with these two types of compliance are similar and both can take place at the office of the Secretary of State, it's important not to confuse the two to ensure nonprofits meet all of their state compliance obligations.
Charitable Solicitation Requirements and Exemptions Vary Widely
The District of Columbia and 39 states currently require some form of charitable registration prior to solicitation of charitable donations by most nonprofit organizations. In addition to one time or annual registration, most of these states require filings in the form of an annual report, renewal, update or some form of compliance filing to remain in good standing with the state charity bureau, usually a division of the Secretary of State or Office of the Attorney General. However, in some of these states, nonprofits are exempt from registration based on the type of charitable activity (e.g. religious organizations, hospitals, educational institutions and small nonprofits), but the requirements for exemption vary widely and, in some cases, require an application.
Ironically, some states exempt certain nonprofit organizations from the registration requirement, but then mandate the filing of an exemption application to do so, often requiring an annual filing to maintain the exemption. Furthermore, there are unusual exceptions, such as in Missouri where 501(c)(3) nonprofit organizations are not required to register and in Louisiana, where only charitable organizations that use a professional solicitor are required to register annually.
Requirements for Qualification and a Registered Agent in Some States
In a few states, the charitable solicitation registration requirements mandate that a charity also qualify to do business in the state and file the appropriate foreign qualification paperwork with the Corporations Division of the Secretary of State. In these states and in a handful of others, a registered agent is also required to fulfill charitable registration and compliance obligations. In order to maintain foreign qualification status in the states that require this, corporate annual reports must be filed with the Secretary of State.
Additional Documents Required With Charitable Solicitation Compliance Filings
Documents that must accompany annual charitable solicitation compliance filings usually include the nonprofit's Form 990 (IRS annual return), audited financial statements and/or state-specific financial reports. Documents that must be filed by nonprofit organizations with initial registrations (and sometimes annual registrations) can also include:
articles and bylaws
lists of officers and directors (sometimes with home addresses and phone numbers)
Form 990 and/or audited financial statements
IRS Determination Letter and/or Application for Exemption (IRS Form 1023 or 1024)
fundraiser contracts and/or copies of direct-mail solicitations
Unified Registration Statement Form Not Accepted "Uniformly" in All States
Filing charitable registration and compliance documents can be done with a uniform form known as the Unified Registration Statement or URS. However, a careful review of state requirements reveals that three states do not accept this form for the initial registration, many more require the URS to be accompanied by state-specific addendums and 13 states do not accept the URS for annual renewal or compliance purposes. Furthermore, some state registration and renewal forms are easier to complete, are prone to fewer rejections or requests for additional information or offer online filing options that facilitate the filing process and reduce errors. After factoring in the above shortcomings and benefits to using some state forms and filing procedures, the URS is not so "unified" after all.
Online Filing of State Charitable Registrations
Online filing is available in a handful of states and is required in Colorado, Hawaii and New Mexico. Rhode Island requires all filings to be submitted on CD.
In some states, a licensing office handles charitable solicitation registration and compliance. For example, in Washington, D.C., a Basic Business License/Charitable Solicitation is required to be filed at the business licensing unit of the Department of Consumer and Regulatory Affairs (DCRA). The title of this filing is a misnomer...there is nothing "basic" about it. A more appropriate name for this filing would be "Complicated Business License". The initial registration filing must include all of the following:
Basic Business License Application
Unified Registration Statement
Certificate of Occupancy
Certified Resolution
DCRA Clean Hands Certification
Office of Tax and Revenue Registration or Exemption
Evidence of corporate qualification in D.C.
Purpose Statement
IRS Determination Letter
The nonprofit's charter and bylaws
Itemized financial statement
Fundraiser contracts
Of course fees, payment methods, due dates, signatures, required notarizations and a variety of other filing factors vary by state. Suffice it to say that nonprofit charitable registration compliance is not an easy task to fulfill or manage.
Consequences of Failing to Comply: The Importance of Getting State Nonprofit Compliance Right
It is imperative that nonprofit organizations fulfill all state corporate and charitable compliance obligations in a timely and accurate manner. Compliance is not an option; it's the law, and noncompliance, late filings or material false statements in registration and renewal filings can be costly in many ways. Though penalties and late fees vary widely, the states are more uniformly aggressive in terms of enforcement.
Charitable compliance penalties and late fees can be quite onerous. Late fees are often hundreds of dollars and penalties for organizations that solicit charitable donations in a state without registering or renewing are sometimes thousands of dollars. Also, with shrinking state budgets in many states, regulators are redoubling their enforcement and collection efforts.
For example, penalties relating to the violation of Alabama law governing charity registration include civil, criminal and monetary penalties up to $25,000. Other penalties include cancellation of registration and enjoining the charitable organization and other persons from continuing the solicitation or collection of funds. This is especially true when deceit or fraud is involved, which can result in misdemeanor and felony criminal charges and imprisonment.
Failure to submit the annual report on Form RRF-1 annually in California, no later than 4.5 months after the end of the organization's accounting period, may result in the loss of tax exemption and the assessment of a minimum tax of $800, plus interest and/or fines or filing penalties as defined in Government Code section 12586.1.
In Illinois, a $100 late report filing fee is required by Illinois law. Because this is a statutory fine, the state will not waive this fee.
In South Carolina, failure to submit an annual financial report by the due date may result in a fine of up to $2,000.
When a finding is made of a violation of the act or rules of New Jersey, in addition or as an alternative to revocation or suspension of a registration, a person may be ordered to pay civil penalties of up to $15,000 and be required to return contributions.
In New York, an organization's registration is automatically revoked if it fails to comply with Article 7-A reporting requirements. The Attorney General may also seek civil penalties of $1,000 per violation and up to $100 per day for noncompliance with reporting requirements.
Pennsylvania publishes on its website a list of outstanding cease and desist orders issued against charitable organizations since 1996. These organizations cannot legally solicit contributions in Pennsylvania until they register with the Bureau of Charitable Organizations or provide the bureau with evidence that they are excluded or exempt from the law. The state also publishes consent agreements and adjudications entered into between the Commonwealth and charitable organizations. On March 8, 2011, a consent agreement was entered into with Cancer Federation, Inc., wherein the charity agreed to pay a $4,000 fine and agreed to voluntarily surrender its registration as a charitable organization in Pennsylvania for a period of 5 years.
If you fail to renew a registration in Virginia, a $100 late fee is imposed and may result in the issuance of a press release, as provided in Section 57-52 of the Code of Virginia, warning the public that the charity has not complied with the law.
Summary of Possible Consequences for Noncompliance with State Charitable Solicitation Requirements
In summary, the more damaging consequences of failing to register or meet compliance requirements include:
Civil and criminal penalties
Publicly announced cease and desist orders
Forced return of charitable donations
Taxation of all charitable donations received
Loss of ability to raise funds in a state
Loss of tax-exempt status
Civil and criminal prosecution of officers and directors
In light of these consequences, it is critically important to make sure state charitable registration and compliance requirements are met. Those responsible need to thoroughly research each applicable state's requirements and carefully fulfill these obligations or outsource the responsibility to a service company, such as NCR, that has the expertise to provide guidance and ensure that all state registration and compliance obligations are satisfied.
Charitable Solicitation Requirements and Exemptions Vary Widely
The District of Columbia and 39 states currently require some form of charitable registration prior to solicitation of charitable donations by most nonprofit organizations. In addition to one time or annual registration, most of these states require filings in the form of an annual report, renewal, update or some form of compliance filing to remain in good standing with the state charity bureau, usually a division of the Secretary of State or Office of the Attorney General. However, in some of these states, nonprofits are exempt from registration based on the type of charitable activity (e.g. religious organizations, hospitals, educational institutions and small nonprofits), but the requirements for exemption vary widely and, in some cases, require an application.
Ironically, some states exempt certain nonprofit organizations from the registration requirement, but then mandate the filing of an exemption application to do so, often requiring an annual filing to maintain the exemption. Furthermore, there are unusual exceptions, such as in Missouri where 501(c)(3) nonprofit organizations are not required to register and in Louisiana, where only charitable organizations that use a professional solicitor are required to register annually.
Requirements for Qualification and a Registered Agent in Some States
In a few states, the charitable solicitation registration requirements mandate that a charity also qualify to do business in the state and file the appropriate foreign qualification paperwork with the Corporations Division of the Secretary of State. In these states and in a handful of others, a registered agent is also required to fulfill charitable registration and compliance obligations. In order to maintain foreign qualification status in the states that require this, corporate annual reports must be filed with the Secretary of State.
Additional Documents Required With Charitable Solicitation Compliance Filings
Documents that must accompany annual charitable solicitation compliance filings usually include the nonprofit's Form 990 (IRS annual return), audited financial statements and/or state-specific financial reports. Documents that must be filed by nonprofit organizations with initial registrations (and sometimes annual registrations) can also include:
articles and bylaws
lists of officers and directors (sometimes with home addresses and phone numbers)
Form 990 and/or audited financial statements
IRS Determination Letter and/or Application for Exemption (IRS Form 1023 or 1024)
fundraiser contracts and/or copies of direct-mail solicitations
Unified Registration Statement Form Not Accepted "Uniformly" in All States
Filing charitable registration and compliance documents can be done with a uniform form known as the Unified Registration Statement or URS. However, a careful review of state requirements reveals that three states do not accept this form for the initial registration, many more require the URS to be accompanied by state-specific addendums and 13 states do not accept the URS for annual renewal or compliance purposes. Furthermore, some state registration and renewal forms are easier to complete, are prone to fewer rejections or requests for additional information or offer online filing options that facilitate the filing process and reduce errors. After factoring in the above shortcomings and benefits to using some state forms and filing procedures, the URS is not so "unified" after all.
Online Filing of State Charitable Registrations
Online filing is available in a handful of states and is required in Colorado, Hawaii and New Mexico. Rhode Island requires all filings to be submitted on CD.
In some states, a licensing office handles charitable solicitation registration and compliance. For example, in Washington, D.C., a Basic Business License/Charitable Solicitation is required to be filed at the business licensing unit of the Department of Consumer and Regulatory Affairs (DCRA). The title of this filing is a misnomer...there is nothing "basic" about it. A more appropriate name for this filing would be "Complicated Business License". The initial registration filing must include all of the following:
Basic Business License Application
Unified Registration Statement
Certificate of Occupancy
Certified Resolution
DCRA Clean Hands Certification
Office of Tax and Revenue Registration or Exemption
Evidence of corporate qualification in D.C.
Purpose Statement
IRS Determination Letter
The nonprofit's charter and bylaws
Itemized financial statement
Fundraiser contracts
Of course fees, payment methods, due dates, signatures, required notarizations and a variety of other filing factors vary by state. Suffice it to say that nonprofit charitable registration compliance is not an easy task to fulfill or manage.
Consequences of Failing to Comply: The Importance of Getting State Nonprofit Compliance Right
It is imperative that nonprofit organizations fulfill all state corporate and charitable compliance obligations in a timely and accurate manner. Compliance is not an option; it's the law, and noncompliance, late filings or material false statements in registration and renewal filings can be costly in many ways. Though penalties and late fees vary widely, the states are more uniformly aggressive in terms of enforcement.
Charitable compliance penalties and late fees can be quite onerous. Late fees are often hundreds of dollars and penalties for organizations that solicit charitable donations in a state without registering or renewing are sometimes thousands of dollars. Also, with shrinking state budgets in many states, regulators are redoubling their enforcement and collection efforts.
For example, penalties relating to the violation of Alabama law governing charity registration include civil, criminal and monetary penalties up to $25,000. Other penalties include cancellation of registration and enjoining the charitable organization and other persons from continuing the solicitation or collection of funds. This is especially true when deceit or fraud is involved, which can result in misdemeanor and felony criminal charges and imprisonment.
Failure to submit the annual report on Form RRF-1 annually in California, no later than 4.5 months after the end of the organization's accounting period, may result in the loss of tax exemption and the assessment of a minimum tax of $800, plus interest and/or fines or filing penalties as defined in Government Code section 12586.1.
In Illinois, a $100 late report filing fee is required by Illinois law. Because this is a statutory fine, the state will not waive this fee.
In South Carolina, failure to submit an annual financial report by the due date may result in a fine of up to $2,000.
When a finding is made of a violation of the act or rules of New Jersey, in addition or as an alternative to revocation or suspension of a registration, a person may be ordered to pay civil penalties of up to $15,000 and be required to return contributions.
In New York, an organization's registration is automatically revoked if it fails to comply with Article 7-A reporting requirements. The Attorney General may also seek civil penalties of $1,000 per violation and up to $100 per day for noncompliance with reporting requirements.
Pennsylvania publishes on its website a list of outstanding cease and desist orders issued against charitable organizations since 1996. These organizations cannot legally solicit contributions in Pennsylvania until they register with the Bureau of Charitable Organizations or provide the bureau with evidence that they are excluded or exempt from the law. The state also publishes consent agreements and adjudications entered into between the Commonwealth and charitable organizations. On March 8, 2011, a consent agreement was entered into with Cancer Federation, Inc., wherein the charity agreed to pay a $4,000 fine and agreed to voluntarily surrender its registration as a charitable organization in Pennsylvania for a period of 5 years.
If you fail to renew a registration in Virginia, a $100 late fee is imposed and may result in the issuance of a press release, as provided in Section 57-52 of the Code of Virginia, warning the public that the charity has not complied with the law.
Summary of Possible Consequences for Noncompliance with State Charitable Solicitation Requirements
In summary, the more damaging consequences of failing to register or meet compliance requirements include:
Civil and criminal penalties
Publicly announced cease and desist orders
Forced return of charitable donations
Taxation of all charitable donations received
Loss of ability to raise funds in a state
Loss of tax-exempt status
Civil and criminal prosecution of officers and directors
In light of these consequences, it is critically important to make sure state charitable registration and compliance requirements are met. Those responsible need to thoroughly research each applicable state's requirements and carefully fulfill these obligations or outsource the responsibility to a service company, such as NCR, that has the expertise to provide guidance and ensure that all state registration and compliance obligations are satisfied.
Sabtu, 30 September 2017
Medical Regulatory Consultancy - Ushering A New Era In Life Sciences
The requirement of pioneering solutions in medicine is only possible now with regulations that define the right research. It also means approval of the right solutions with the help of consultation to aid development. It goes for big pharma players as well as the upcoming new companies that look at life sciences as their goal to provide quality medical devices. It is a team effort and the medical device regulatory consulting is an important agency that explores several customized options specific to various pharma companies.
The life science industry is expanding at an unprecedented pace. With constant research and technology available, many new devices and methodologies are being invented. With regular research it has also become critical to ensure that there are regulations for improvement of medical sciences. It is true concern on the part of the government that they strive for quality and perfection. Medical devices play a very important role in diagnostic processes. Thus, it is important on the part of the government to maintain highest standards to regulate them. But it is not always easy to maintain the highest standards. On many occasions the concerned firms fail to retain the standards specified the concerned government authority. One of the major causes for such failure is lack of knowledge. But such scenario can be successfully battled with correct consulting and training processes.
Medical device consulting firms provide with specifically trained professionals who help in obtaining quality and compliance for all type of medical devises. The proper methodology, skills and tools have a positive impact on the overall performance. Medical Device regulatory consulting is absolutely necessary for maintenance of quality systems. This is will help in meeting the strictest challenges posed by the regulatory authorities. One can choose from a number of medical device training courses. It is ideal to have umbrella coverage on all the issues arising inside the life science industry.
* Risk management - It is vital for the firms to have professionals with effective risk management training. They must go for training program that teaches to identify budding problems, method for checking the problem and prevention of future re-occurrence of similar situation.
* Documenting investigation- It is very important to have clear, comprehensive and effective documents. Any firm with professional who are trained in preparing such documents will be able in handling government authorities better. They must be trained with by experienced trainers to present the necessary data in crystal clear method.
* Medical Device Analysis- The professionals must be trained in order to conduct audit process for the medical devices and data. The medical devices must be put under regular audit in order to maintain quality. They must be trained for conducting both supplier and internal audits.
The professionals are equipped with a clear idea about analytical problem solving and quality system regulation.
In addition to training programs, the firms are assisted with consultation in specific areas like CAPA Systems, Management Control, Investigation facilitation and auditing. With specific suggestions from expert professionals in all the areas, the life science industry can address some of its problems in more organized way.
The life science industry is expanding at an unprecedented pace. With constant research and technology available, many new devices and methodologies are being invented. With regular research it has also become critical to ensure that there are regulations for improvement of medical sciences. It is true concern on the part of the government that they strive for quality and perfection. Medical devices play a very important role in diagnostic processes. Thus, it is important on the part of the government to maintain highest standards to regulate them. But it is not always easy to maintain the highest standards. On many occasions the concerned firms fail to retain the standards specified the concerned government authority. One of the major causes for such failure is lack of knowledge. But such scenario can be successfully battled with correct consulting and training processes.
Medical device consulting firms provide with specifically trained professionals who help in obtaining quality and compliance for all type of medical devises. The proper methodology, skills and tools have a positive impact on the overall performance. Medical Device regulatory consulting is absolutely necessary for maintenance of quality systems. This is will help in meeting the strictest challenges posed by the regulatory authorities. One can choose from a number of medical device training courses. It is ideal to have umbrella coverage on all the issues arising inside the life science industry.
* Risk management - It is vital for the firms to have professionals with effective risk management training. They must go for training program that teaches to identify budding problems, method for checking the problem and prevention of future re-occurrence of similar situation.
* Documenting investigation- It is very important to have clear, comprehensive and effective documents. Any firm with professional who are trained in preparing such documents will be able in handling government authorities better. They must be trained with by experienced trainers to present the necessary data in crystal clear method.
* Medical Device Analysis- The professionals must be trained in order to conduct audit process for the medical devices and data. The medical devices must be put under regular audit in order to maintain quality. They must be trained for conducting both supplier and internal audits.
The professionals are equipped with a clear idea about analytical problem solving and quality system regulation.
In addition to training programs, the firms are assisted with consultation in specific areas like CAPA Systems, Management Control, Investigation facilitation and auditing. With specific suggestions from expert professionals in all the areas, the life science industry can address some of its problems in more organized way.
Minggu, 10 September 2017
Burnt Offerings - Sacrificing Insurance and Investment Clients to the Altars of Greed and Compliance
According to Webster, compliance is normally defined as "the act of conforming, acquiescing, or yielding." Within the insurance and investment world it means a company department dedicated to interpreting the laws governing the industry, dictating policy to the employees and investigating violations. It is populated with lawyers and examiners who do their best to keep the company out of trouble with the state and federal governments. Any agent who receives a client complaint falls under the scrutiny of the compliance department. Once identified, regardless of the validity of the complaint, the agent is considered guilty until proven innocent.
Compliance departments rapidly expanded following a feeding frenzy of corrupt life insurance sales across the United States during the 1980s and early 1990s. Few insurance companies were immune to the rampant manipulation of money in old life insurance policies for the sole purpose of creating sales of new policies. These actions weren't some crackpot ideas initiated by desperate agents or ignorant clients. The sales campaigns were carefully planned and executed at the highest levels of company executives. The upper management of the companies ordered agents to revisit all existing clients with sufficient monetary value in their old policies and offer them more life insurance for "free."
The sales concept was deceptively simple. A cooperating agent just needed to examine the life insurance records of his body of clients, find the ones who had money built up inside the policy or policies, meet with the client to "review" their coverage, point out all the unused value languishing unproductively inside the dusty old policy and propose using it to buy more "tax free" death benefit for the client's family. The clincher to the sale was when the agent appealed to the client's greed by telling them that they would never have to pay a dime for it. The clients were told that the money inside the old policies would take care of the new ones for the rest of their lives.
Insurance sales skyrocketed, with many agents being so successful that they rapidly climbed the corporate ladder into upper management, where they could spread their sales ideas throughout the company. Big money from the sales commissions and bonuses allowed agents to qualify for special sales conferences to posh resorts where they could learn even newer sales techniques to enhance their careers. Everyone involved was "in the money," and there appeared to be no end to the profits. As long as there continued to be plenty of stored cash in old insurance policies, easy sales kept happening. It didn't matter to the insurance companies that the clients were being encouraged to take money out of one pocket and put it into another just for the sake of generating sales and commissions. Management looked good because the sales of new policies were up, the agents using the dubious techniques were making money, and the greedy clients believed they were getting something for nothing. Nearly everyone was happy.
Reality reared its ugly head when interest and dividend rates dropped from the inflationary levels of the 1980s. The old dusty life insurance policies could no longer support the new "free" ones. The bubbling spring of cash flowing into them dried up and all the grand plans for a rosy guaranteed secure future evaporated. Both the old and new policies failed leaving the clients with no legacy for their families. Lawsuits against the insurance companies and their agents piled up, as did complaints to the state and federal regulatory departments. Any time that government is caught napping, when it wakes up and has to deal with legal turmoil and bailouts it becomes an angry, heavy-fisted rampaging giant.
The insurance companies were investigated and rightfully found guilty of misrepresenting their products to their clientele. It was exposed that the programs for the sale of "free" life insurance policies existed purely for the sake of generating commissions and provided little or no overall benefit to the clients. The scale of the corruption was so vast that full monetary compensation for the losses was impossible. The corruption in many of the largest companies reached into the billions of dollars. For those clients still alive, settlements were offered and eventually accepted.
Within the government mandates, insurance companies were required to create compliance departments to oversee, investigate and regulate their sales practices and promise that the clients would never be wrongly taken advantage of again. By forcing the companies to be self-policing, governmental authorities thought they could better control the potential for corruption and mismanagement, at least until the next corporate disaster hit the public.
Ordering a company that deals exclusively with huge amounts of money to self-police is much like a shepherd trusting his flock of sheep to wolves merely because he's threatened them with death if any more hanky-panky goes on. The reality is that there are far too many sheep for the shepherd to tend and there are plenty of hungry wolves looking for loopholes in the extinction clause. Yet, most insurance company compliance departments follow the letter of the law, if not the spirit, that governs them, maintaining at least the appearance of ethical behavior.
The shepherd does come back on occasion and count the number of sheep. Not being totally naïve, he expects to see some violations of the rules, and the wolves make sure there are sufficient sacrifices to appease him. Compliance knows that a report of perfect conformity to the regulations makes the government nervous, and the last thing the company wants is to be audited. Within this need to satisfy the governmental regulators and follow only the letter of the law lie the tragic moral and ethical shortcomings of compliance departments. To stay away from governmental scrutiny, compliance departments discourage honest agents from attempting to help clients who are victims of misrepresentation and corruption by other companies. For the sake of convenience, the spirit of the anti-corruption laws and regulations plus the trust the client has in their agent are violated.
Any good agent can quickly spot cases of misrepresentation or instances where the client was a victim of fraud. Because most people don't make an effort to educate themselves about their insurance products, many don't realize that they've been taken to the cleaners. Many generous and honest agents will devote time at their own expense to help these clients understand the whys and hows of the fraud that was perpetrated. This may not only be an attempt to help a good client, but also an act of professionalism and pride in the quality of their work. As in all professions, there are good and bad people. Clients are lucky to have such an advocate, even though many don't understand or appreciate the value of the agent's services.
Unfortunately, fewer and fewer agents are willing to risk the ire of their company's compliance department or state and federal regulators by helping with complaints of fraud. A visit from insurance regulators or company compliance investigators can aptly be compared to an audit by the IRS. If an agent tries to help a client file a complaint against another insurance company or agent, his motives may be immediately questioned and his actions examined. Not only are all of the helping agent's records dealing with the cheated client gone over, but his entire body of clientele may also be reviewed. When that happens, simple human error in the form of an outdated brochure or misfiled form could result in sanctions and fines. The agent's act of professionalism and charity becomes a costly form of punishment.
When an honest and experienced agent identifies a case of insurance related fraud, difficult moral and ethical questions arise. Will anyone appreciate not only the effort, but also the potential trouble the agent may create for himself by alerting the client and helping them resolve the issue? Or, is ignoring the crime by saying nothing and choosing self-preservation the best course of action? It's a quandary that only the agent has to face and resolve. Insurance fraud is a nearly unmanageable result of greed created by an industry fueled by money that affects everyone involved.
Compliance departments rapidly expanded following a feeding frenzy of corrupt life insurance sales across the United States during the 1980s and early 1990s. Few insurance companies were immune to the rampant manipulation of money in old life insurance policies for the sole purpose of creating sales of new policies. These actions weren't some crackpot ideas initiated by desperate agents or ignorant clients. The sales campaigns were carefully planned and executed at the highest levels of company executives. The upper management of the companies ordered agents to revisit all existing clients with sufficient monetary value in their old policies and offer them more life insurance for "free."
The sales concept was deceptively simple. A cooperating agent just needed to examine the life insurance records of his body of clients, find the ones who had money built up inside the policy or policies, meet with the client to "review" their coverage, point out all the unused value languishing unproductively inside the dusty old policy and propose using it to buy more "tax free" death benefit for the client's family. The clincher to the sale was when the agent appealed to the client's greed by telling them that they would never have to pay a dime for it. The clients were told that the money inside the old policies would take care of the new ones for the rest of their lives.
Insurance sales skyrocketed, with many agents being so successful that they rapidly climbed the corporate ladder into upper management, where they could spread their sales ideas throughout the company. Big money from the sales commissions and bonuses allowed agents to qualify for special sales conferences to posh resorts where they could learn even newer sales techniques to enhance their careers. Everyone involved was "in the money," and there appeared to be no end to the profits. As long as there continued to be plenty of stored cash in old insurance policies, easy sales kept happening. It didn't matter to the insurance companies that the clients were being encouraged to take money out of one pocket and put it into another just for the sake of generating sales and commissions. Management looked good because the sales of new policies were up, the agents using the dubious techniques were making money, and the greedy clients believed they were getting something for nothing. Nearly everyone was happy.
Reality reared its ugly head when interest and dividend rates dropped from the inflationary levels of the 1980s. The old dusty life insurance policies could no longer support the new "free" ones. The bubbling spring of cash flowing into them dried up and all the grand plans for a rosy guaranteed secure future evaporated. Both the old and new policies failed leaving the clients with no legacy for their families. Lawsuits against the insurance companies and their agents piled up, as did complaints to the state and federal regulatory departments. Any time that government is caught napping, when it wakes up and has to deal with legal turmoil and bailouts it becomes an angry, heavy-fisted rampaging giant.
The insurance companies were investigated and rightfully found guilty of misrepresenting their products to their clientele. It was exposed that the programs for the sale of "free" life insurance policies existed purely for the sake of generating commissions and provided little or no overall benefit to the clients. The scale of the corruption was so vast that full monetary compensation for the losses was impossible. The corruption in many of the largest companies reached into the billions of dollars. For those clients still alive, settlements were offered and eventually accepted.
Within the government mandates, insurance companies were required to create compliance departments to oversee, investigate and regulate their sales practices and promise that the clients would never be wrongly taken advantage of again. By forcing the companies to be self-policing, governmental authorities thought they could better control the potential for corruption and mismanagement, at least until the next corporate disaster hit the public.
Ordering a company that deals exclusively with huge amounts of money to self-police is much like a shepherd trusting his flock of sheep to wolves merely because he's threatened them with death if any more hanky-panky goes on. The reality is that there are far too many sheep for the shepherd to tend and there are plenty of hungry wolves looking for loopholes in the extinction clause. Yet, most insurance company compliance departments follow the letter of the law, if not the spirit, that governs them, maintaining at least the appearance of ethical behavior.
The shepherd does come back on occasion and count the number of sheep. Not being totally naïve, he expects to see some violations of the rules, and the wolves make sure there are sufficient sacrifices to appease him. Compliance knows that a report of perfect conformity to the regulations makes the government nervous, and the last thing the company wants is to be audited. Within this need to satisfy the governmental regulators and follow only the letter of the law lie the tragic moral and ethical shortcomings of compliance departments. To stay away from governmental scrutiny, compliance departments discourage honest agents from attempting to help clients who are victims of misrepresentation and corruption by other companies. For the sake of convenience, the spirit of the anti-corruption laws and regulations plus the trust the client has in their agent are violated.
Any good agent can quickly spot cases of misrepresentation or instances where the client was a victim of fraud. Because most people don't make an effort to educate themselves about their insurance products, many don't realize that they've been taken to the cleaners. Many generous and honest agents will devote time at their own expense to help these clients understand the whys and hows of the fraud that was perpetrated. This may not only be an attempt to help a good client, but also an act of professionalism and pride in the quality of their work. As in all professions, there are good and bad people. Clients are lucky to have such an advocate, even though many don't understand or appreciate the value of the agent's services.
Unfortunately, fewer and fewer agents are willing to risk the ire of their company's compliance department or state and federal regulators by helping with complaints of fraud. A visit from insurance regulators or company compliance investigators can aptly be compared to an audit by the IRS. If an agent tries to help a client file a complaint against another insurance company or agent, his motives may be immediately questioned and his actions examined. Not only are all of the helping agent's records dealing with the cheated client gone over, but his entire body of clientele may also be reviewed. When that happens, simple human error in the form of an outdated brochure or misfiled form could result in sanctions and fines. The agent's act of professionalism and charity becomes a costly form of punishment.
When an honest and experienced agent identifies a case of insurance related fraud, difficult moral and ethical questions arise. Will anyone appreciate not only the effort, but also the potential trouble the agent may create for himself by alerting the client and helping them resolve the issue? Or, is ignoring the crime by saying nothing and choosing self-preservation the best course of action? It's a quandary that only the agent has to face and resolve. Insurance fraud is a nearly unmanageable result of greed created by an industry fueled by money that affects everyone involved.
Kamis, 31 Agustus 2017
Electronic Medical Billing Dashboard Software - 9 Performance Indicators For Service Outsourcing
Arcane terminology and complex rules for payer- and time-dependent claim validity and pricing interpretation plague medical billing industry, resulting in massive payments of invalid or ineligible claims and denials of error-free claims. The amount and complexity of billing information make it very difficult for the doctor to maintain compliance and identify and resolve errors and underpayments.
"With integrated Billing Transparency, I see for myself how Vericle leverages every opportunity to expedite payments of healthcare insurance claims in a continuous 24 x 7 effort. It has enabled 27% revenue gain over past billing process," says Doug Cassel, M.D., Director of Interventional Radiology at Hoag Memorial Hospital in Newport Beach, California.
Greater visibility of internal process activities promotes teamwork, increases client satisfaction, and assists in process streamlining. Billing service transparency allows participants of the billing process to expedite error identification and resolution, resulting in reduced over- and under-payments and improved regulatory compliance.
1. Billing Dashboard as Main Transparency Mechanism
Selection of meaningful and intuitive indicators for billing process performance is a mission-critical stage in the process of creating a useful transparency mechanism. A dashboard presenting such most meaningful data must be easy to find and simple for interpretation. Cumulative experience of hundreds of doctors using Vericle-like billing technologies, has shown that a dashboard containing nine specific indicators expedite the development of intuitive and powerful transparency mechanisms:
Month-to-date collections
Total failed or denied claims
Aggregate failed or denied claims in follow-up queue
Dollar Accounts Receivable (AR) below 30 days,
$ AR in ( 30, 120] days
$ AR > 120 days
Percent Accounts Receivable (AR) below 30 days,
% AR in ( 30, 120] days,
% AR > 120 days
Note that national average of percent accounts receivable above 120 days hovers around 18%. Therefore, a well-performing outsourced billing service must deliver % AR > 120 days significantly below 18%. Specifically, to justify its fees, an outsourced billing service must measure its AR > 120 days anywhere around 5%.
2. Drill-down Functionality, Reporting, and Transparency
Advanced dashboard allows drill-down for more detail directly by pointing and clicking the cursor at the dashboard. At the minimum, the following features must be available:
Operational Report shows total claims and $ amounts submitted, paid, adjusted, written off, and failed. It allows breakdown by CPT code, payer, referral, or a combination of such dimensions.
Denials Report shows the list of denied claims and a log of followup actions. By sorting it by amount paid, you can tell the smallest payment the billing service will fight for.
Compliance Report shows the potential for post-payment audit and itemizes compliance violations.
These reports allow multiple dimensions for data presentation, by single parameter, such as, payer, CPT code, provider, or referring physician, or by more complex parameter combinations, such as pairs of payer-CPT code, provider-CPT code, or referring physician-CPT code.
3. Complexity Considerations
Note that even a small single-provider practice working with 20 CPT codes and 20 payers, has 400 (20x20) payer-CPT code pairs. Therefore, an on-line report comparing month-to-date collections between current and previous years requires powerful database query capability. Moreover, automation of such queries like "find the worst performing payer for the best performing CPT code" requires OLAP technology.
4. Summary
Billing Transparency is a necessary feature of a modern and accountable billing service. Billing Transparency allows the practice owner to know both the big picture and minute detail of billing process. To be able to observe every step of the billing process on a continuous 24 x 7 basis, reporting must be available using a secure HIPAA compliant connection over the Internet. While traditional services delivered monthly paper reports, modern technology allows the delivery of continuously updated and meaningful billing performance data.
"With integrated Billing Transparency, I see for myself how Vericle leverages every opportunity to expedite payments of healthcare insurance claims in a continuous 24 x 7 effort. It has enabled 27% revenue gain over past billing process," says Doug Cassel, M.D., Director of Interventional Radiology at Hoag Memorial Hospital in Newport Beach, California.
Greater visibility of internal process activities promotes teamwork, increases client satisfaction, and assists in process streamlining. Billing service transparency allows participants of the billing process to expedite error identification and resolution, resulting in reduced over- and under-payments and improved regulatory compliance.
1. Billing Dashboard as Main Transparency Mechanism
Selection of meaningful and intuitive indicators for billing process performance is a mission-critical stage in the process of creating a useful transparency mechanism. A dashboard presenting such most meaningful data must be easy to find and simple for interpretation. Cumulative experience of hundreds of doctors using Vericle-like billing technologies, has shown that a dashboard containing nine specific indicators expedite the development of intuitive and powerful transparency mechanisms:
Month-to-date collections
Total failed or denied claims
Aggregate failed or denied claims in follow-up queue
Dollar Accounts Receivable (AR) below 30 days,
$ AR in ( 30, 120] days
$ AR > 120 days
Percent Accounts Receivable (AR) below 30 days,
% AR in ( 30, 120] days,
% AR > 120 days
Note that national average of percent accounts receivable above 120 days hovers around 18%. Therefore, a well-performing outsourced billing service must deliver % AR > 120 days significantly below 18%. Specifically, to justify its fees, an outsourced billing service must measure its AR > 120 days anywhere around 5%.
2. Drill-down Functionality, Reporting, and Transparency
Advanced dashboard allows drill-down for more detail directly by pointing and clicking the cursor at the dashboard. At the minimum, the following features must be available:
Operational Report shows total claims and $ amounts submitted, paid, adjusted, written off, and failed. It allows breakdown by CPT code, payer, referral, or a combination of such dimensions.
Denials Report shows the list of denied claims and a log of followup actions. By sorting it by amount paid, you can tell the smallest payment the billing service will fight for.
Compliance Report shows the potential for post-payment audit and itemizes compliance violations.
These reports allow multiple dimensions for data presentation, by single parameter, such as, payer, CPT code, provider, or referring physician, or by more complex parameter combinations, such as pairs of payer-CPT code, provider-CPT code, or referring physician-CPT code.
3. Complexity Considerations
Note that even a small single-provider practice working with 20 CPT codes and 20 payers, has 400 (20x20) payer-CPT code pairs. Therefore, an on-line report comparing month-to-date collections between current and previous years requires powerful database query capability. Moreover, automation of such queries like "find the worst performing payer for the best performing CPT code" requires OLAP technology.
4. Summary
Billing Transparency is a necessary feature of a modern and accountable billing service. Billing Transparency allows the practice owner to know both the big picture and minute detail of billing process. To be able to observe every step of the billing process on a continuous 24 x 7 basis, reporting must be available using a secure HIPAA compliant connection over the Internet. While traditional services delivered monthly paper reports, modern technology allows the delivery of continuously updated and meaningful billing performance data.
Selasa, 15 Agustus 2017
The Science of Compliance - Creating a Comprehensive Compliance Program
The rule for compliance is that it should define the actions we must take or refrain from or the ends we must achieve. Today, a smaller organization, typically, goes through one form or another of an audit process maybe 10 times a year, while for larger companies it could be well hundreds more if they're in an industry that has active vendor management programs.
When the Unified Compliance Framework (UCF) started in 2005, the creation rate of authority documents was not as high as it is today. With strict norms calling for an organization to harness these rules of compliance and governance, there is even more compliance pressure on companies. Compliance sets the boundaries around their activities, configurations and reporting.
The UCF is perhaps one of the few IT compliance frameworks that help you manage conflicting and overlapping compliance requirements across hundreds of different regulations, allowing you to comply with many requirements including PCI, Sarbanes-Oxley, HIPAA, CobiT, NIST, and hundreds more.
UCF helps you understand and implement the science behind compliance management utilizing automated assessments and audits over 600 regulations and industry standards. Such a control framework can enable you to reduce compliance costs, expand compliance coverage, and reduce risk by:
• Tracking all applicable regulations in a common control framework
• Efficiently create and distribute policies according to job function
• Maintain an auditable record of policy acceptance and training
• Prioritize compliance deficiencies with an overall risk methodology
• Manage remediation and charting progress toward organization objectives
An automated compliance process and workflow will allow you to assess if controls have been appropriately implemented across your business, identify gaps across business processes, assets, and also plan remediation activity.
The UCF has unique data architecture and is capable of tracking a wide variety of authority documents, individual originators and issuers, terms and acronyms and then threading them into the framework's database in a meaningful way.
The key advantage of the UCF is the head start it provides an organization in understanding and planning compliance issues. Imagine if you had to sift through 4000-5000 controls in your organization. You would never be able to get your GRC efforts off the ground if you have to do all the heavy lifting by yourself.
Typical Control Framework Design Process
1. Identify regulations and internal standards that apply to the organization
2. Apply the control framework to the organization
3. Align policies, procedures and standards with your organizational control framework
4. Perform assessments to identify control deficiencies
5. Prioritize deficiencies based on consistent risk methodology
6. Plan and manage remediation activity
Being able to adjust to new or updated regulatory regulations or just keeping track of compliances and managing your own control framework can be a daunting task. Organizations should focus on the activities and the actions associated with getting better at compliance, governance and risk as opposed to the activity of being able to collate all these regulations into a common set of controls.
Of course, you need to be careful in selecting such a vendor, making sure that the vendor is speeding up the compliance process. Your vendor should be able to:
1. Eliminate redundant compliance activities and tasks, saving time and improving manageability
2. Help the management's ability to access current compliance status, such as enabling them to run their own reports versus having to respond to ad hoc requests for data
3. Simplify communication of compliance status to stakeholders
4. Improve visibility into current compliance status and accelerate business-critical decisions
5. Select a viable GRC program that is:
a. Automated
b. Scalable
c. Easy-to-implement
d. Quick and efficient
e. Designed to suit specific organization needs
When the Unified Compliance Framework (UCF) started in 2005, the creation rate of authority documents was not as high as it is today. With strict norms calling for an organization to harness these rules of compliance and governance, there is even more compliance pressure on companies. Compliance sets the boundaries around their activities, configurations and reporting.
The UCF is perhaps one of the few IT compliance frameworks that help you manage conflicting and overlapping compliance requirements across hundreds of different regulations, allowing you to comply with many requirements including PCI, Sarbanes-Oxley, HIPAA, CobiT, NIST, and hundreds more.
UCF helps you understand and implement the science behind compliance management utilizing automated assessments and audits over 600 regulations and industry standards. Such a control framework can enable you to reduce compliance costs, expand compliance coverage, and reduce risk by:
• Tracking all applicable regulations in a common control framework
• Efficiently create and distribute policies according to job function
• Maintain an auditable record of policy acceptance and training
• Prioritize compliance deficiencies with an overall risk methodology
• Manage remediation and charting progress toward organization objectives
An automated compliance process and workflow will allow you to assess if controls have been appropriately implemented across your business, identify gaps across business processes, assets, and also plan remediation activity.
The UCF has unique data architecture and is capable of tracking a wide variety of authority documents, individual originators and issuers, terms and acronyms and then threading them into the framework's database in a meaningful way.
The key advantage of the UCF is the head start it provides an organization in understanding and planning compliance issues. Imagine if you had to sift through 4000-5000 controls in your organization. You would never be able to get your GRC efforts off the ground if you have to do all the heavy lifting by yourself.
Typical Control Framework Design Process
1. Identify regulations and internal standards that apply to the organization
2. Apply the control framework to the organization
3. Align policies, procedures and standards with your organizational control framework
4. Perform assessments to identify control deficiencies
5. Prioritize deficiencies based on consistent risk methodology
6. Plan and manage remediation activity
Being able to adjust to new or updated regulatory regulations or just keeping track of compliances and managing your own control framework can be a daunting task. Organizations should focus on the activities and the actions associated with getting better at compliance, governance and risk as opposed to the activity of being able to collate all these regulations into a common set of controls.
Of course, you need to be careful in selecting such a vendor, making sure that the vendor is speeding up the compliance process. Your vendor should be able to:
1. Eliminate redundant compliance activities and tasks, saving time and improving manageability
2. Help the management's ability to access current compliance status, such as enabling them to run their own reports versus having to respond to ad hoc requests for data
3. Simplify communication of compliance status to stakeholders
4. Improve visibility into current compliance status and accelerate business-critical decisions
5. Select a viable GRC program that is:
a. Automated
b. Scalable
c. Easy-to-implement
d. Quick and efficient
e. Designed to suit specific organization needs
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