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We are your go to partners for answers to questions about healthcare compliance, medical credentialing, contracting, policies and procedures, workforce training and many more.
A1: Healthcare compliance is the ongoing process of meeting, or exceeding the legal, ethical, and professional standards applicable to a particular healthcare organization or provider. Healthcare compliance requires healthcare organizations and providers to develop effective processes, policies, and procedures to define appropriate conduct, train the organization’s staff, and then monitor the adherence to the processes, policies, and procedures. Healthcare compliance covers numerous areas including, but not limited to, patient care, billing, reimbursement, managed care contracting, OSHA, Joint Commission on Accreditation of Healthcare Organizations, NCQA, and HIPAA privacy and security to name a few.
A2: The governing body of a healthcare organization is responsible for the conduct of the organization. Consequently, the governing body and the executive officers of the healthcare organization will bear the ultimate responsibility for a healthcare organization’s compliance, or lack of compliance.
The organization’s governing body is responsible for directing the organization’s administrators to develop and implement the organization’s compliance program, as well as, authorizing funds to accomplish the task.
A3: Every healthcare organization and provider is required to have a compliance program immediately. In fact, every healthcare organization and provider should have already established a healthcare compliance program. A large healthcare organization must have a comprehensive compliance program involving numerous individuals from multiple disciplines. Federal and state healthcare laws and regulations change constantly and the interpretation of those laws and regulations changes just as frequently. Effective healthcare compliance must be an ongoing process of continually reviewing and updating the processes, policies, and procedures of the organization. The organization also must continually update the training provided to its employees based upon changes in the regulations.
A4: Ultimately, the purpose and primary benefit of healthcare compliance is to improve patient care and safety. Patient care is improved when healthcare decisions are based upon appropriate and current clinical standards. Patient care decisions based upon improper motives rarely results in the delivery of quality care. Healthcare compliance also aids healthcare organizations and providers in avoiding trouble with government authorities.
A5: It is nearly impossible to overstate the complexity of healthcare compliance. The avalanche of laws, rules, regulations, and standards that apply to healthcare organizations and healthcare providers is daunting. Healthcare organizations and providers need an individual, or individuals, that can assist them in the development, implementation, and management of an effective healthcare compliance program.
The chief compliance officer is the point person that makes sure the healthcare compliance program is kept current, including all the policies and procedures that are part of the compliance program. In a large healthcare organization that job cannot be accomplished by a single individual. Large organizations will require multiple individuals, and whole departments devoted to healthcare compliance. Healthcare compliance is cumbersome, perhaps overly cumbersome, but it is here to stay.
A6: Yes. Our pricing is scaled based on the types of services needed and number of users, if applicable. This allows small groups to have access to the same program and level of support as medium and large health care organizations.
A7: Yes. Within the healthcare industry, there are statutes that support the need for annual training on HIPAA, OSHA, and Corporate Fraud, Waste & Abuse regulations.
A8: You can sign up for services by calling us or completing our contact form to begin the process. As our partner, you work with and are assigned an account manager who is responsible for understanding your needs and program requirements, contracting and for your billing.
A10: To keep the costs down, we generally like to work with our partners remotely through phone, email, and online conferencing, but we are available to come onsite to perform setups or mock audits and workforce training, if needed.
A1: The credentialing process is the health care industry standard to collect and verify each health care professional’s qualifications.
A2: Credentialing assesses qualifications, relevant training, licensure, certification and/or registration to practice for each health care professional who participates in a health plan’s networks and/or holds privileges in a hospital or health system. This process ensures patient safety and quality of care being provided to patients.
A3: Credentialing occurs before a health care professional is considered eligible to participate in a health plan’s network or granted privileges to see patients in a hospital or facility.
Q4: Credentialing standards are set by the National Committee on Quality Assurance (NCQA), as well as specific state and federal regulations for participation in the Medicaid and Medicare programs. Most credentialing processes comply with these standards. Some states may have additional requirements as part of the credentialing and recredentialing process.
A5: Commercial insurance carriers or health plans vary widely in their turnaround time of your requests for credentialing and contracting. Most major carriers can complete the process in 90 – 120 days. Smaller regional or local plans may take even longer.
Medicare and Medicaid applications may take 30 to 90 days to be approved, even though we’ve seen some applications submitted approved within a week. Note: Application for Medicaid participation is usually contingent upon participation in Medicare.
Commercial carriers do not allow for retroactive billing. Until you have a complete contract and are listed “In-Network” in the carrier claims system then you will not receive in-network reimbursement for your claims. While billing out of network, your patients will receive a much higher bill for your services and possibly be responsible for 100% of your charges.
A6: YES. Even though we cannot make insurance companies process your credentialing application any faster than they normally would, we understand the process well and avoid mistakes often made by providers attempting to handle the process themselves, thereby improving the credentialing time. Our efficiency in managing the overall process, preparing the initial credentialing applications, and regular follow-up on submitted credentialing applications with carriers helps us cut down on the time it takes to get you approved and considered in-network.
We are thrilled to answer any questions you have about SimpliCompliance and the ways we can help meet your organization’s needs.
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