The Vital Importance of Regulatory Compliance in Healthcare

compliance and regulatory services

In the realm of healthcare, regulatory compliance is a cornerstone of operations. It involves adhering to laws, guidelines, and standards established by various governmental and industry authorities. Regulatory compliance in healthcare is paramount, ensuring the safety of patients, the integrity of the healthcare system, and the prevention of legal and financial consequences. In this blog, we will explore why regulatory compliance in healthcare is of utmost importance, highlighting the role of regulatory compliance solutions and consultants in maintaining this critical aspect of the industry.

Patient Safety and Quality of Care

Perhaps the most crucial reason for regulatory compliance in healthcare is patient safety and the delivery of high-quality care. Regulations exist to ensure that healthcare providers meet specific standards that protect patients from harm, whether through medical errors, substandard facilities, or unethical practices. Compliance with regulations directly correlates with improved patient outcomes and a reduced risk of adverse events.

Legal Consequences

Failure to comply with healthcare regulations can result in severe legal consequences, including fines, penalties, and even criminal charges. Healthcare organizations that neglect compliance put their reputation and financial stability at risk. Regulatory compliance solutions help mitigate these risks by establishing robust systems and processes to adhere to regulatory requirements.

Financial Stability

Regulatory compliance is closely linked to financial stability in healthcare. Non-compliance can lead to fines and penalties that strain a healthcare organization’s resources. Additionally, healthcare providers that rely on government reimbursements, such as Medicare and Medicaid, must adhere to specific regulations to continue receiving payments. Regulatory compliance consultants play a pivotal role in helping organizations maintain financial health by navigating complex regulations.

Maintaining Reputation and Trust

Trust is essential in healthcare. Patients must trust their healthcare providers to deliver safe and effective care. Non-compliance can result in negative publicity, eroding patient trust and damaging an organization’s reputation. Regulatory compliance helps healthcare organizations maintain the trust of their patients and the broader community they serve.

Efficient Operations

Regulatory compliance solutions and consultants assist healthcare organizations in streamlining their operations. By ensuring adherence to regulations, these solutions help identify inefficiencies, reduce waste, and optimize processes. This not only improves patient care but also contributes to cost savings.

Data Security and Privacy

In an era of digital healthcare, protecting patient data is paramount. Regulatory compliance, such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States, establishes guidelines for data security and privacy. Failure to comply with these regulations can result in data breaches, exposing patients to identity theft and healthcare fraud.

Avoiding Penalties

Healthcare regulatory bodies often impose significant penalties for non-compliance. These penalties can include fines, sanctions, or even the revocation of licenses and certifications. Regulatory compliance consultants specialize in helping healthcare organizations understand and meet these regulations to avoid such penalties.

Staying Current with Evolving Standards

Healthcare regulations are not static; they evolve to address emerging challenges and technologies. Staying current with these changes is a complex task. Regulatory compliance consultants are well-versed in the latest regulatory developments, ensuring that healthcare organizations remain up-to-date and compliant.

Regulatory compliance in healthcare is not a mere checkbox; it’s a fundamental aspect that ensures patient safety, maintains financial stability, and upholds trust within the industry. Regulatory compliance solutions and consultants play a crucial role in helping healthcare organizations navigate this complex landscape. By adhering to regulations, healthcare providers not only protect themselves from legal and financial consequences but also ensure the well-being and trust of their patients. In an ever-changing healthcare landscape, staying compliant is not just important—it’s essential.

What Is Regulatory Compliance in Healthcare?

Healthcare Compliance Insurance Hospital Work concept. Doctor offers shield scales icon on a virtual graphical user interface.

Maintaining compliance is a critical factor for healthcare companies and those who work in the healthcare industry. Many federal laws and statutes not only define what it means to be out of compliance but also what the penalties are for violation of compliance standards.

When regulatory standards are not maintained, healthcare professionals may face legal charges and also be ordered to pay heavy fines and potentially lose their ability to practice their profession in the medical industry.

What Is Healthcare Compliance?

Healthcare compliance in the medical and dental industry is defined by maintaining federal regulations with a focus on high ethical standards in patient care.

On a day-to-day basis, this can look like continually assessing and updating processes in order to prevent fraud, patient abuse, and waste across departments.

Some of the laws that govern healthcare compliance include the following:

  • Anti-Kickback Statute(AKBS): This federal law prevents anyone from giving or receiving anything of value, including money, in exchange for facilitating the sale of healthcare services or treatment, especially when federal healthcare dollars are covering the cost of that treatment. Violations are criminal in nature.
  • Stark Law: Similar to AKBS, the Stark Law forbids doctors from referring patients to other physicians or service providers with whom they have a financial relationship, especially if the services are paid for by Medicare. Penalties are outlined for violations.
  • Emergency Medical Treatment and Labor Act(EMTALA): Specific to hospitals, this law requires that stabilizing treatment be provided to all who enter in need of treatment regardless of their ability to pay for medical services.

There are also laws that pertain to specific jobs and address issues of patient understanding of care and options, ending a medical relationship with a patient, and provision of care.

To ensure that your organization is in full compliance with all federal regulatory laws and standards, it is a good idea to meet with a legal team who is up to date on current regulations.

How to Maintain Regulatory Healthcare Compliance

If you would like to learn more about how to maintain regulatory healthcare compliance or improve compliance standards within the company, contact Florida Healthcare Law Firm today. We can help you ensure the following:

  • Current policies and procedures are up to date
  • Education and training are available to employees to ensure continued compliance
  • Reporting, monitoring, and auditing are consistent and thorough
  • Enforcement measures are in place

Call Florida Healthcare Law Firm today to set up your initial consultation.

DME Scheme of Greed Knows No Bounds

Durable Medical EquipmentBy: Susan St. John

In yet another take-down of an illicit scheme to defraud the Medicare Program and ChampVA, as well as other insurers, Patsy Truglia has been sentenced to 15 years in federal prison. He has also had assets forfeited since these assets were acquired with money from his ill-gotten fraud scheme. In total, Mr. Truglia and his co-conspirators collected approximately $18.5 million from Medicare, ChampVA, and insurance using a scheme of telemarketing, telemedicine, and multiple DME providers or “store fronts.”

The scheme used telemarketers to collect beneficiaries personal and medical information to create orders for DME products such as knee, back, and wrist braces. These orders were then provided to telemedicine practitioners for signature – often without a valid telehealth communication. In essence, there was no attempt at having a practitioner exercise independent judgment as to the medical necessity of these DME products. Instead, these practitioners were paid for their signatures on the pre-filled order forms as part of the “scheme of greed.” From January 2018 to 2019, this scheme of greed resulted in approximately $12 million in payment to Truglia and his co-conspirators.Continue reading

Florida Medical License Renewal

health care professionals attorney

In the state of Florida, medical professionals are required to renew their licenses every two years.

The idea is to ensure that the individual is still capable of performing their job, remains current on training and other relevant certifications, and has no outstanding issues in terms of investigations or job performance.

The medical license renewal process in Florida is relatively simple in most cases, but if there are any outstanding issues or unresolved questions, it can take some maneuvering to finalize the renewal.

Keep It Simple: Renew Your Florida Medical License Online and Early

As long as you do not have to change the status of your license, your license status is not “Military, Active,”, “Delinquent, Active,” or “Delinquent, Inactive,” you should not have a problem renewing your license online. Simply follow the link for your profession on the Florida Board of Medicine website to complete the process online.

Additionally, if you choose to renew your medical license in Florida before it expires, you have the benefits of getting the lowest fee options available.

Should you attempt to renew your license after your license expires, the fee can more than double, and if you try to new your Florida medical license more than 120 days after expiration, at which point you are considered Notified Delinquent, the fee can rise another 25 percent.

Requirements for Renewing Via a Florida Medical License by Mail

If you’re “Military, Active,” need to change your name on your license, need to change your status, or need to pay with a check or cashier’s check rather than a credit card, you can apply for medical license renewal by mail.

All the same dates and deadlines apply, so it’s important to keep that in mind when you choose the timing to mail the application for renewal, leaving enough time for it to arrive in advance of the deadline.

Florida Medical License Renewal Requirements

Whether you file online or by mail, you will need the correct forms, fully filled out and signed, as well as the required fee, including late fees if applicable.

However, if your status is currently “Delinquent, Active” or “Delinquent, Inactive,” your process will be slightly more complex.

You will need to contact the Florida Board of Medicine to discuss the details of your case and what is required of you going forward. Depending on the issue causing your status disruption, you may need to take classes, acquire referral letters, work with a mentor, or provide other services.

If you have already completed the requirements necessary to clear your status and renew your medical license, it may be just a matter of documenting your compliance to move forward.

Help With Medical License Renewal in Florida

If you are running up against obstacles getting your medical license renewed in Florida and you need help, reach out to Florida Healthcare Law Firm today and find out how we can help you expedite the process.

OIG Revises Self-Disclosure Protocol

On November 8, 2021, The Department of Health & Human Services (HHS), Office of Inspector General (OIG) released a revised and renamed Provider Self-Disclosure Protocol (SDP), now known as the “Health Care Fraud Self Disclosure “protocol. The SDP was created in 1998, and the protocol can be used to voluntarily identify, disclose and resolve instances of potential fraud involving federal healthcare programs. As described on the OIG website, “Self-disclosures give persons the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation.”Continue reading

Genetic Testing: Be Hopeful but Wary

Genetic tests are valuable because they can provide important information to patients and their medical providers regarding diagnoses, treatment, and disease prevention. However, the rapid growth in the number of tests ordered, especially in light of the telemedicine expansion during the pandemic, has invited well-earned scrutiny to the industry.

Make no mistake: genetic testing is heavily regulated (and enforced). The Federal Anti-Kickback Statute, Eliminating Kickbacks in Recovery Act, and Commercial Insurance Fraud Law have all been used to prosecute unscrupulous marketers, call centers, and telemedicine providers in the last few months. Kickbacks in exchange for genetic specimens are just as illegal as kickbacks for patients. Three months ago, a Florida man was sentenced to 10 years in prison for conspiracy to commit health care fraud. His actions resulted in the submission of approximately $3.3 million in fraudulent claims to Medicare for genetic testing.Continue reading

6 Essential Questions For Audit Preparedness

medical practice audit

medical practice auditBy: Zach Simpson

As you train your staff on the changes that were recently made regarding evaluation and management coding it is very important to ensure that your staff understands the auditor’s perspective as well. There are four distinct portions of an auditor’s tool when evaluating the documentation guidelines for office/outpatient evaluation and management (E/M) services (99202-99215). The four distinct portions are diagnoses, data, risk, and calculation of medical decision making (MDM).  In order to ensure that a provider’s progress note is complete in the auditor’s eyes the provider should ask themselves the following six questions to create the best chances of successfully meeting the auditors expectations:

  1. Does my progress note contain a medically appropriate history and examination?
  2. Were my diagnoses addressed appropriately?
  3. Did I document all orders and data reviewed?
  4. Were other professionals included in my documentation that I worked with?
  5. Was an independent historian used?
  6. Does the documentation support the level of risk I chose?

For the remainder of the article, I am going to dive deeper into each question above so that you, as providers are able to recognize insufficient areas in a provider’s E/M documentation when you perform a self audit to better your practice.Continue reading

Buying a Dental Practice? Here’s What to Consider

tips for buying a dental practice

tips for buying a dental practiceBy: Chase Howard

Whether you’ve been in practice for years or you’re just graduating, buying an existing dental practice can be a great way to quickly enter into an already established patient base without the pains of starting up from scratch. While it may seem like a daunting task, the right team can make the purchase transaction flow as smoothly as possible. Here’s a list of important things to consider when negotiating the purchase.

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Health Care Fraud Enforcement Got You Worried?

healthcare fraud in 2020

healthcare fraud in 2020By: Karen Davila

Healthcare fraud continues to be a significant priority for the U.S. Department of Justice.  On February 24, 2021, the DOJ’s Criminal Division Fraud Section published its annual “Fraud Section Year in Review 2020.”  While the Fraud Section has three separate enforcement units, the Health Care Fraud (HCF) Unit is responsible for all enforcement activities in the health care industry.  The Unit’s focus is to protect against fraud and abuse in federal health care programs and recoup illicit gains.

During 2020, the HCF Unit operated 15 strike forces in 24 federal judicial districts throughout the U.S.  The efforts of these strike forces led to charges against 167 individuals alleging $3.77 billion in fraudulent charges for health care paid for by federal and state programs.  This should cause any health care provider to stand up and take notice.  And enforcement in the health care industry is not likely to go away soon with so many schemes ripe for the government’s picking and generating recoupment on behalf of the federal health care programs.

Here are couple of the latest schemes that have landed pharmacies, pharmacists and other health care professionals squarely in the crosshairs of federal enforcement:

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