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U.S. Healthcare Industry Challenged with Managing Regulatory, Compliance Risk

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Managing regulatory and compliance risk in the face of constantly evolving rules and guidelines is a significant challenge for both the payers and the providers who make up the United States’ healthcare industry, creating a market need for systems that can consistently support regulatory, reimbursement and compliance professionals.

A June 2017 white paper from management consulting firm Frost & Sullivan, The Increasing Challenge of Managing Regulatory and Compliance Risk, explores what is needed to create an information platform that manages compliance needs. The document discusses the state regulatory issues in flux, health insurance exchanges (HIXs), and how those exchanges will be governed by regulations that were issued by the Department of Health and Human Services in December 2016.

Factors underscoring the need for a comprehensive information platform  include:

  • Organizational complexity: U.S. healthcare is heavily regulated by a combination of federal, state, and local government agencies as well as private standard-setting organizations.
  • New payment models: Laws and regulations are continually revised or reinterpreted. For instance, recently passed federal-level legislation, such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the 21st Century Cures Act, are set to disrupt current physician payment and hospital reimbursement under Medicare.
  • Evolving compliance risks: Changes to procedures and diagnostic codes in the ICD-10, standards for electronic patient records and privacy, and basic operations regulated by government agencies will require immediate compliance for providers to reduce their risk.

According to Frost & Sullivan, the ideal information platform will possess the following attributes:

  • Software as a Service (SaaS) option that provides current awareness on a daily basis and is a complete workflow solution.
  • A very deep archive of primary source regulatory and reimbursement content, plus treatises, guides, cases, and white papers developed by industry experts.
  • Access to a high-quality legal research platform.
  • Up-to-date coding and coverage information.
  • Ability to connect fragmented processes and silos of information along the governance, risk management, and compliance functions.
  • Possess applications that comprehensively cover incident reporting, issue tracking and management, surveys, and audit management, as well as contract, vendor and document management.
  • Allows healthcare organizations to assess and mitigate privacy and information security risk across the enterprise.

This white paper is not only a blueprint for software and information suppliers; it also provides an overview of the true complexities and challenges inherent in setting up and running U.S. (or U.S.-compliant or U.S.-compatible) healthcare or health insurance products and services.

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