Webinar Recap: 3 Compliance Monitoring Trends Impacting Healthcare in 2023

jan 2023 pt webinar

In a recent webinar, ProviderTrust took a look at impactful healthcare trends to monitor in 2023 and beyond. Hosted by Co-Founder of ProviderTrust Michael Rosen and Chief Compliance Officer Donna Thiel, our webinar outlined various factors affecting the healthcare space in the new year, from staffing strikes to increased scrutiny around private equity investment firms.

These are our healthcare industry priorities for 2023 and beyond:

  1. Cost containment
    • The impact of labor
    • Staffing challenges
  2. Mergers, acquisitions, and consolidations
    • Health systems and health plan partnerships
    • Increased scrutiny around private equity firms
  3. Government oversight surrounding Telehealth
    • Increase of Telehealth
    • The OIG’s Special Fraud alert

Cost Containment

Many health systems across the US have recently had to address financial pressures. In a recent study by Becker’s Hospital Review, 17 different hospitals reported having to scale back for a variety of reasons, including staffing issues and financial challenges. Six health systems either reduced services, closed hospitals or practice locations, while five health systems re-engineered leadership and/or their corporate structure to save money. Within the 17 total health systems included in the study, over 3500 positions were cut.

According to a January 2023 Washington Post article, nurses across California, Oregon, Michigan, and Minnesota have also threatened to protest or have already gone on employment strike. The National Council for the State Boards of Nursing has indicated that in 2021, there were 4.4 million registered nurses, but the Department of Labor reported that only 3 million were employed. Another 100,000 nurses left the industry between 2020 and 2021, according to an industry trade-journal estimate, either to retire early, leave the field, or switch jobs.

Staffing challenges and financial setbacks can often give rise to significant risk.

Ask yourself:

  • How are providers filling these open positions?
  • Are appropriate practitioner checks being completed to ensure proper credentials and eligibility to work?
  • What does this mean for compliance and oversight or management of these risks?

Mergers, Acquisitions, and Consolidation

Mergers and acquisitions have been steadily increasing again. With the aforementioned cost consolidations, buyers and sellers are more financially distressed than before. Some companies might be selling because they don’t have the capital they need, while others may be refocusing on core business and shedding underperforming units. Now more than ever, mergers are focused on cost efficiency and financial stability.

Private equity (PE) firms and investors have also faced recent challenges; they are being faced with heavier scrutiny and potential exposure to liability under the False Claims Act. The government and private whistleblowers have increasingly targeted PE firms’ portfolio companies and the firms themselves. According to Nashville law firm Bass, Berry & Sims, PLC, PE firms and owners have been named as defendants and agreed to pay funds to settle various recent FCA enforcement actions. One recent settlement we covered on our blog detailed the Massachusetts Attorney General’s case against South Bay Mental Health Centers. In this instance, the private equity investors and former CEOs were held personally liable and settled for a total of $25 million.

With so many factors accounting for new mergers and acquisitions and the growing scrutiny around PE firms and investors, health systems should consider new tactics to stay compliant.

Ask yourself:

  • When do you find out about upcoming organizational changes? Knowing when acquisitions are coming can help you better prepare for changes.
  • Do you have a compliance checklist? What questions would you ask the current organization you are acquiring as it relates to its existing compliance program?
  • What is their standard of practice for conducting exclusion monitoring? What about license verification and screening? Do you have any risk based on poor standards of practice?
  • Are you buying a distressed asset with a lack of focus on compliance and regulations?

Government Oversight

On January 30, 2023, President Biden announced that the COVID-19 national and public health emergency (PHE) would end on May 11, 2023, allowing several months for providers and healthcare organizations to prepare. With this announcement comes a series of changes, including payment related to COVID-19 testing and treatment as well as Medicaid coverage. There were numerous licensure extensions and flexibilities at various times throughout the PHE. From a compliance perspective, it is imperative for compliance managers to look closely at the policies and protocols that may have changed during the PHE and determine if updates are needed to ensure compliance when the PHE ends.

On December 29, 2022, President Biden signed the Consolidated Appropriations Act into law. This includes a number of provisions related to Medicaid and the Children’s Health Insurance Program (CHIP), but certain flexibilities were also extended to Telehealth until the end of 2024. In some ways, this can be interpreted as the Telehealth industry being given a chance to continue establishing its value and worth.

A September 2022 report by the OIG found that Telehealth visits increased drastically after the onset of the COVID-19 pandemic. In 2022, 37 million people utilized Telehealth visits— a 13-fold increase from 2021. However, there has been increased scrutiny of Telehealth organizations. The OIG identified several integrity risks associated with billing for Telehealth services, including inappropriate billing for the highest, most expensive level of Telehealth services and risks related to duplicate claims and high-volume billing.

The OIG’s study also found that many programs lacked the data necessary for proper oversight. In July 2022, the OIG issued a Special Fraud Alert urging providers to exercise caution before entering into arrangements with telemedicine companies. One common fraud characteristic in Telehealth companies involves a patient being recruited by a telemedicine company through an advertisement for free or low out-of-pocket cost items or services. Another common fraud tactic includes compensating practitioners based on the volume of services in an attempt to incentivize those practitioners.

Now that the OIG has issued a fraud alert for Telehealth companies, organizations should consider enhanced oversight regarding compliance monitoring.

Companies should:

  • Conduct additional monitoring of Telehealth services
  • Develop additional billing controls to prevent inappropriate claims submission
  • Create and conduct education for providers and individuals about Telehealth services
  • Increase follow-up surveys for patients to ensure satisfaction and identify potential concerns
  • Identify the possible quality of care metrics to add to current monitoring
  • Create an audit plan to increase the potential for self-identification of issues

How ProviderTrust Can Help You Solve These Challenges

ProviderTrust simplifies and automates the license and credential monitoring process for healthcare’s top HR and compliance teams in one powerful platform. Working as a complement to existing credentialing processes, ProviderTrust provides up to daily exact match results from the primary source, monitoring all 50 states and all boards. This allows healthcare organizations to focus on their patients with in-house and contracted staff, saving time and money while ensuring credentials are always in good standing. Accessible healthcare does not have to compromise the standard of care.

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