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Real-time data will transform compliance program effectiveness

The hidden obstacle to achieving consistent compliance with Centers for Medicare & Medicaid Services (CMS)
and state-level regulatory requirements—ever since the Social Security Act[1] gave the secretary authority to require Medicare and Medicaid entities to establish compliance programs in 2010—is getting access to real-time data. Unfortunately, most compliance teams still analyze and react to data through the rearview mirror.

Yes, nearly a decade of fines and penalties have motivated widespread adoption of board-level oversight regarding organizational risk and the implementation of enterprise-wide compliance programs. But the complexity of governance, risk, and compliance (GRC) processes makes maintaining an efficient compliance program a daunting task, especially when data reside across disconnected departments and databases.
The result? Compliance teams continuously chase data to catch up with the realities affecting their healthcare organizations today. Unfortunately, the reality of manually implemented compliance programs is that by the time a report is requested or an audit hits, compliance teams are already late.
Here’s the good news. Several medium and large health plans have implemented real-time compliance technologies that empower their compliance teams to move from being reactive data chasers to acting as proactive GRC process managers who add value to the bottom line by preventing noncompliance before it occurs. These forward-looking health plans transformed their compliance program effectiveness by leveraging big data to deliver continuously compliant results in relative real time.

Cost of manual compliance programs

Why are manual processes so reactive and inefficient? After all, they all should be, and probably are, following
the Office of Inspector General and CMS model for success.[2] Wouldn’t complying with these elements ensure that compliance teams can easily generate clean universes and submit error-free reports in a timely manner?

Conceptually, in an ideal world free from external influences, the best practices laid out in these seven fundamental elements are reasonable. On paper, the plans look both comprehensive and preventive.

However, the reality is easily exposed by briefly examining traditional compliance program processes at each fundamental stage. The outcomes, while not surprising, cry out for more efficient solutions.

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