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.

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