Q&A Maintaining Ongoing Compliance

Join our experienced senior consultants as they respond to questions regarding accreditation ongoing compliance maintenance.

Questions include:

1. What software program can be used to assist with ongoing compliance maintenance?

2. What suggestions do you have for keeping up to date with state and federal regulations?

3. If you are assessing your program on a quarterly basis, does URAC expect to see an annual report also?

4. What services does Integral Healthcare Solutions (IHS) provide to help organizations stay in compliance?

Our Integral Healthcare Solutions (IHS) experts are: Dr. Thomas Goddard, the CEO Lesley Malus Reed, the President Susan DeMarino, the Compliance Officer Sana Wrigley, the COO.

See more educational accreditation-related videos here.

Transcription

[00:00:00.440]

[00:00:10.000] - Sanalynn Wrigley

My name is Sanalynn Wrigley, and I am the Chief Operating Officer of Integral Healthcare Solutions. So grateful that all of you have taken the time in your day to come join us. So without further ado, I will go ahead and introduce our panel today. To start us off, we have Thomas Goddard.

[00:00:29.750] - Thomas Goddard

Hi

[00:00:29.980] - Sanalynn Wrigley

Tom is our CEO and runs the whole show. Tom, tell us a little bit about yourself.

[00:00:37.180] - Thomas Goddard

I got involved with URAC 20 years ago. I joined URAC as the Chief Operating Officer and General Counsel. And in addition to those responsibilities, also served as a reviewer on the health plan and health network at first, and then website, and then others over the years. And I founded this company, Integral Healthcare Solutions, in 2002. And we've been working with URAC and other accreditation organizations ever since then, mainly working with organizations seeking accreditation from URAC. By training, I'm a lawyer and an industrial organizational psychologist. I live in sunny Tucson.

[00:01:26.480] - Sanalynn Wrigley

Thank you, Tom. Next up, we have Lesley Malus Reed, Company President for IHS. Lesley, introduce yourself.

[00:01:33.630] - Lesley Malus Reed

Hi, good afternoon, everybody. I started in the Canadian healthcare system, and I joined IRAC in 1997 and helped develop a lot of the credentialing network health plan standards. I've been helping applicants get ready for accreditation here at IHS since 2003. That's when I joined Tom to do that, after we've been on the road for many years as reviewers together.

[00:01:58.430] - Sanalynn Wrigley

Awesome. Thank you. And last but certainly not least... Sue DeMarino, former Vice President of URAC and our Chief Clinical Officer.

[00:02:08.750] - Sue DeMarino

Hi, everyone. As Sana has indicated, I was at URAC for 17 years, started in 1999 as their primary case management reviewer, and through the years had many positions. I left there approximately three years ago and joined Tom and Lesley and the gang. I'm here at IHS. And my background is I'm a registered nurse. I have a master's in healthcare administration, and I'm really excited to be here today.

[00:02:41.710] - Sanalynn Wrigley

Thank you, Sue. The first question on our list, what software program is most commonly used to assist with ongoing compliance maintenance?

[00:02:50.760] - Thomas Goddard

Well, I'll say briefly ours. We developed a few years ago a piece of software called Goldfinch that is now... We used it primarily to interface with our clients during the actual accreditation, reaccreditation process. But since we've launched our ongoing compliance maintenance program, and that's what we're launching last year, our clients are now using that. And other software that we've come across, Compliance 360, we've come across a lot. It is for some of our clients, more ornate and difficult to learn than their organizations could tolerate. But it's a very robust, for some organizations, it's a very robust and perfectly appropriate good tracking software. Before Goldfinch, we used spreadsheets. And it was as painful as it was. It was a whole lot better than nothing.

[00:03:58.400] - Lesley Malus Reed

So if you're going from multiple accreditations, historically, there was 360, compliance 360. And it's been very interesting to us to develop our Goldfinch. And we are spending some time looking into what we can do to make it even better for future use, for both multiple accreditations and for ongoing compliance.

[00:04:26.510] - Sanalynn Wrigley

All right, our next question has five votes for it, suggestions on keeping up with state and federal regulations.

[00:04:37.840] - Thomas Goddard

I'll lead out, and I know Sue and Lesley likely have some comments here. For me, this is exactly like what I faced in 1994, when all of a sudden, for the first time in my life, I was a general counsel of a large health plan that operated in multiple jurisdictions. And I walked in and said, Now that I have the job of making sure we don't break the law, I asked my staff, What are the laws we're not supposed to break? And they pointed at a shelf of law books. They said, Well, right over there. There's the Maryland Code. No, no, no, that we need something much better than that. Because what became really immediately clear to me, and this is reflected in URAC interpretation of its compliance standards, Core Four and PCP One, is there are really two pieces to tracking the laws and regulations that apply to you. First of all, you've got to get your arms around the laws and regulations, both state and federal, that apply to you today. What are those? And that would be HIPAA. That would be, if you're a specialty pharmacy, the pharmacy licensing laws. It's both the general healthcare laws that apply to everybody, fraud, waste, abuse, and so on, and those that apply to your organization today based on what you do, whether you're a specialty pharmacy, or health plan, or case management organization, and so on.

[00:06:03.310] - Thomas Goddard

But that's only half the issue. The other half of the issue is tracking the changes in those laws. And so it's really two rather distinct kinds of tracking mechanisms. You've got to build a database, whether it's in a spreadsheet or something like Goldfinch, piece of software like Goldfinch, or some software to keep track of that existing database. It was so overwhelming to me as a first time general counsel. I just had my associate general counsel do that for about two months. It literally lists every law that applies to us and what the ramifications are that on our behavior as a health plan. But then you've got to keep your eye on, how do you know how that changes? It could be involvement in a trade association's legislative committee. It could be receiving newsletters either from a trade association or from a regulator or both. CMS, for example, Center for Medicare and Medicaid Services puts out regular bulletins to certain entities, and you make sure you get on and read that list. And so it's going to vary depending on the organization you are and where you operate, and the organizations both private and public that are associated with your line of business.

[00:07:30.340] - Thomas Goddard

And then you've got to have a system for when you do see a change, making sure that something happens to that. I used to work in a subsidiary health plan of a very large national healthcare organization, and I would get these bulletins from the parent organization's legal office. And it took a while for me to figure out that I was supposed to actually, Oh, right, I need to actually make sure that operations knows about this change. And then, well, how do we track that? And then set up a software solution to tracking any information that comes in from any source about changes that were made at the regular or legal, or legislative level.

[00:08:18.430] - Lesley Malus Reed

So if I can summarize, you need to track it, you need to evaluate your current compliance with it, and then you need to disseminate that information down to those whose jobs are going to be affected by it.

[00:08:29.650] - Thomas Goddard

And then circle back around to make sure that they implemented what you told them to implement.

[00:08:34.690] - Lesley Malus Reed

Yes, the evaluation. And then sometimes you'll also find that your client has certain requirements. Your client could be the government, your client could be a carrier. It just depends on your line of business. You're going to need to have an open communication with your clients as well. Sue, I'm sorry.

[00:08:56.850] - Sue DeMarino

That's all right. I'm sorry. I thought you were done speaking. One of the other strategies that I've seen organizations use is to track when a state regulatory body is in session, because then they can track when potential laws are coming up, they'll get a preview, and then once it's passed, some organizations contract with healthcare attorneys that keep track of that information. Some organizations have LexisNexis. There are a lot of strategies that I've seen used throughout my years as a reviewer. And just having that mechanism well-defined, and as both Tom and Lesley spoke about, what is that mechanism to evaluate whether that particular change in the regulation has an impact on your organization is key? Because you need to get subject matter experts at the table from different departments, inter-departmental meetings, because you may not be aware of how that may impact the U. M. Department or the claims department. Having those subject matter experts hearing about the requirements and then them having an aha moment and saying, Hey, that impacts us in a big way, right?

[00:10:15.870] - Thomas Goddard

And, Lesley, you alluded to another source of compliance when you mentioned your company's clients' requirements. This is particularly compelling if your client is the government. If, let's say, your Medicaid Health Plan, or if you're in the Tricare system as either a health network or a health plan, a TRICare contractor health network doesn't really have much law to deal with. Almost everything that a Tricare Health Network has to deal with is in the administrative manual, and that's being changed. We are told by our Tricare clients every single month. So you got to make sure that you're watching all of those bulletins and then taking that to your implementation committee meeting and saying, All right, try to get us done it again. Here's the new requirement, and then audit that that requirement's been implemented in your organization. In our organization, we take a comprehensive approach to contracts, laws, regulations, and accreditation standards, so that we're tracking everything in Goldfinch, including contractual requirements, like liability insurance requirements. We're putting in the Goldfinch so that we don't think of accreditation, and law, and regulation, and contracts as a separate thing. And we're really starting to get a sense of that unified field of compliance helps the whole organization to see really the broad array of external requirements as one thing.

[00:11:54.790] - Sanalynn Wrigley

All right, our next question. If you are assessing your program on a quarterly basis and monitoring performance, does URAC expect to see an annual report separately from the quarterly documentation?

[00:12:08.510] - Lesley Malus Reed

Yes, they do. So you're having your quarterly meetings and you're talking about them and what you discussed in quarter one might be very different from what you discussed in quarter four. And it's important to take a step back and take a look for any trends, any time. So should we retire something now and start something new? What did we learn from all the metrics that we collected? Is there opportunities to improve our satisfaction? Did we identify an issue? It's really important to take that step back, take a look at it. In quality management, you actually have to take it from the quality management committee and send it to a committee that oversees quality management for their assessment and evaluation too.

[00:12:58.840] - Sanalynn Wrigley

Perfect. Thank you. You're welcome. And the next question is, what type of services does your organization provide annually to help organizations stay in compliance and avoid denial of accreditations?

[00:13:13.230] - Thomas Goddard

First of all, we sit down with you and say, All right, who in your organization does this required thing? And what committees do these required things? So we map out on an individual basis what your monthly, quarterly, and annual requirements are, and that's usually based on the accreditation requirements, and we find out who in your organization handles this. Who's the chairman of that committee? Who's the point person on those issues? And then we set up a series of notifications that come out monthly that remind you. Don't forget, this is the month that your quality committee has to do X, Y, and Z. Don't forget, this is when we agreed in our meeting that you need to do this thing. So that's the first thing. We customize a set of reminders to make sure that everybody stays on track throughout every month of the year. And then we do quarterly reviews. And two reviews a year... No, three reviews a year are virtual, and one is on site. One each quarter, we do a review. So let's say you got accredited in January of this year. We would do virtual reviews the second, third, and fourth quarter, and then an on-site review in the first quarter of next year.

[00:14:40.970] - Thomas Goddard

And this is presumption that we can move it to accommodate your particular needs. But this is our template approach. And then we would do virtual file reviews or interviews the second, third, and fourth quarter, and then another on-site review in the first quarter of 2020. We designed the reviews to address both what we think are the likely pain points or problem areas and issues that you may raise. So we'll contact a client whom we owe a quarterly review at the beginning of the quarter. Of course, we're in the middle of that right now at the beginning of the third quarter. And we'll say, Look, you've got a virtual review. What do you want to focus on this month or this quarter? And they might say, Well, it's a credentialing. We've got some real concerns about some organizational changes over in credentialing. Or, You know what? Last quarter, we encountered... Sue uncovered some stuff in our medical management processes, and we'd like to see if we've implemented the fixes to those. And so we will adapt our quarterly, virtual, or onsite reviews to both what we think are the needs and what your organization think are the needs.

[00:15:59.740] - Thomas Goddard

What have I left out, Sana?

[00:16:03.430] - Sanalynn Wrigley

I think that mostly covers it, except for anyone who contracts with us for ongoing compliance does have the option of a number of add-on services that are billed hourly. So if, say, you do your quarterly reviews and you realize you need a much deeper dive, or you need someone to come on site and help implement something, or you need some additional training, all of that is available as part of the package.

[00:16:25.430] - Thomas Goddard

Good point.

[00:16:26.150] - Lesley Malus Reed

Thank you. I'd also say that Sue developed the most beautiful dashboard to help people keep on track for quality. It is tier worthy. She has worked really hard in both quality and in the patient management area, where most of our folks really need a lot of help to maintain. Yeah, one other thing.

[00:16:50.050] - Thomas Goddard

Let me add this and then Sue bounce it to you if you have anything to add. One of the services that all of our ongoing compliance maintenance clients get from us is a license to continue to use Goldfinch. So you can use Goldfinch as an ongoing way of maintaining your accreditation and otherwise compliance world, even if you're done with your accreditation process.

[00:17:23.800] - Sue DeMarino

I have nothing to add. Thank you.

[00:17:25.990] - Sanalynn Wrigley

And I just want to call out Sue is getting some love for that quality dashboard over on the chatbar on the side. It really is an incredible tool. If you have any further questions, you're welcome to reach out. Send us an email. If you have a topic you'd like to see us do a webinar on, go ahead and shoot us an email. Let us know. Thank you very much. And we hope you have an excellent rest of your day.

[00:17:50.620] - Thomas Goddard

Take care, everybody. Thank you. Thanks for coming. Thank you. Bye-bye. Thanks for coming. Bye-bye.