
Looking Closer At Compliance In Healthcare


William Gedman , Vice President, Quality Audit, Fraud & Abuse, Chief Compliance Officer, UPMC Health Plan
Emerging challenges in compliance
The ACA has brought with it ongoing issuance of many new regulations as well as the new commercial marketplaces. In order to function in this new environment, and to be compliant, plans have had to implement new information systems, with logic that is very complex, especially regarding premium subsidies and reconciliation. The new HIPAA Omnibus rule, which just recently went into effect, is challenging because it essentially lowers the bar, if you will, for what is considered a HIPAA breach. It poses more risk for healthcare and health insurance organizations, as they may now come under more scrutiny regarding PHI (personal health information), individual privacy, and data security.
Another challenge is how fraud, waste, and abuse (FWA) has come to be seen by some as a panacea for all of health care’s problems. There’s a lot of pressure from the Federal and state levels to detect and prevent FWA–and to recover or prevent significant amounts of inappropriate provider payments. To do so involves use of complex fraud detection or predictive software, and clinical/investigative staff. At the UPMC Health Plan, we have significantly invested in FWA detection and prevention efforts.
"We always try to be open and proactive with our partners, not just reactive when a potential problem arises"
Creating a link with partners to make compliance work
As part of an integrated delivery and financing system, UPMC Health Plan already has a robust infrastructure regarding payer/provider compliance, as well as auditing, and monitoring. For a health plan, communication with the provider network is key. UPMC Health Plan has open lines of communication with its provider network, and is as transparent as possible regarding compliance requirements and expectations. With employer groups and individual members, we routinely educate and communicate. Other important partners include our regulators. We keep open lines of communication, and appropriately self-report potential compliance issues when necessary. We always try to be open and proactive with our partners, not just reactive when a potential problem.
Check out: Top Healthcare Compliance Solution Companies
ON THE DECK
Featured Vendors
EDITOR'S PICK
Essential Technology Elements Necessary To Enable...
By Leni Kaufman, VP & CIO, Newport News Shipbuilding
Comparative Data Among Physician Peers
By George Evans, CIO, Singing River Health System
Monitoring Technologies Without Human Intervention
By John Kamin, EVP and CIO, Old National Bancorp
Unlocking the Value of Connected Cars
By Elliot Garbus, VP-IoT Solutions Group & GM-Automotive...
Digital Innovation Giving Rise to New Capabilities
By Gregory Morrison, SVP & CIO, Cox Enterprises
Staying Connected to Organizational Priorities is Vital...
By Alberto Ruocco, CIO, American Electric Power
Comprehensible Distribution of Training and Information...
By Sam Lamonica, CIO & VP Information Systems, Rosendin...
The Current Focus is On Comprehensive Solutions
By Sergey Cherkasov, CIO, PhosAgro
Big Data Analytics and Its Impact on the Supply Chain
By Pascal Becotte, MD-Global Supply Chain Practice for the...
Technology's Impact on Field Services
By Stephen Caulfield, Executive Director, Global Field...
Carmax, the Automobile Business with IT at the Core
By Shamim Mohammad, SVP & CIO, CarMax
The CIO's role in rethinking the scope of EPM for...
By Ronald Seymore, Managing Director, Enterprise Performance...
Driving Insurance Agent Productivity with Mobile and Big...
By Brad Bodell, SVP and CIO, CNO Financial Group, Inc.
Transformative Impact On The IT Landscape
By Jim Whitehurst, CEO, Red Hat
Get Ready for an IT Renaissance: Brought to You by Big...
By Clark Golestani, EVP and CIO, Merck
Four Initiatives Driving ECM Innovation
By Scott Craig, Vice President of Product Marketing, Lexmark...
Technology to Leverage and Enable
By Dave Kipe, SVP, Global Operations, Scholastic Inc.
By Meerah Rajavel, CIO, Forcepoint
AI is the New UI-AI + UX + DesignOps
By Amit Bahree, Executive, Global Technology and Innovation,...
Evolving Role of the CIO - Enabling Business Execution...
By Greg Tacchetti, CIO, State Auto Insurance
Read Also
test
The Intersection of Privacy and IT
Stay Connected with Your Stakeholders
Essential to Recognize Traditional and Non-traditional Regulations
Regulatory Scrutiny of Business: Unavoidable
Developing Technology to Address Big Data and Cyber-Security...
