Healthcare Compliance Services

  • ROSALIND CORDINI, JD, MSN

    ROSALIND CORDINI, JD, MSN

    Senior Vice President/Director of Coding & Compliance Services

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Hospitals, health systems, and physician groups are challenged to keep up with the complicated and ever-changing healthcare regulatory environment. At Coker, we have the compliance solution best suited for your organization to respond to the challenge.

Compliance Program Development

An effective compliance program incorporates the seven elements outlined in the Federal Sentencing Guidelines and is in operation within the organizational environment. We are available to assist your organization in developing an individualized, meaningful compliance program, and we help you activate the program within your setting.

Compliance Program Effectiveness Assessment

Healthcare organizations, senior executives, and governing body members are under increasing scrutiny to ensure they have implemented an effective compliance program. We can evaluate your organization’s existing compliance plan against the seven required elements and offer recommendations and implementation assistance to improve the effectiveness of your procedures.

Governance Education and Advisory Services

Governing body members have a fiduciary obligation to understand the compliance program its organization has in place and ensure there is a viable structure for reporting compliance issues to the board. Our experts educate the governing body on its fiduciary obligations regarding compliance, assist in developing the communication sequences, and provide ongoing advisory services on a variety of compliance matters.

Virtual Compliance Officer Services

We have expert compliance resource personnel available to deliver remote compliance officer services on an interim or ongoing basis. Organizations may wish to engage us to assist in operationalizing a newly developed or existing compliance program or provide ongoing compliance program oversight. In addition to providing remote compliance officer services, we can support your organization with interviewing and training a newly-hired compliance officer.

Physician Arrangement Compliance Audits

Some of the highest risks for healthcare organizations revolve around arrangements with physicians. We can assist your organization by performing physician arrangement reviews for Stark/Anti-kickback compliance, physician payment reconciliation reviews, and medical director arrangement/documentation reviews for existing arrangements. Our compliance experts can also assist your organization in ensuring an adequate system is in place to log gifts and other non-monetary compensation to physicians in compliance with the Stark law.

Physician Arrangement Procedure Development

An organizational policy, procedure, and structure that is followed by all individuals involved in the physician arrangements process is critical to mitigating the numerous risks to organizations in the area of arrangements with physicians. Our compliance team can assist you in developing a sound and compliant process and procedure.

Fair Market Value/Commercial Reasonableness Opinions

The three tenets of defensibility surrounding physician compensation arrangements are that 1) the compensation arrangement is within fair market value, 2) is commercially reasonable, and 3) doesn’t take into account the volume or value of referrals or other business generated. Documentation of the facts and circumstances surrounding the basis of a compensation arrangement often supports the commercial reasonableness of an agreement. Our experts are available to provide an objective opinion as to whether a compensation arrangement is within fair market value and is commercially reasonable.

Provider Coding and Documentation Compliance Audits

An essential element of every healthcare organization’s compliance work plan is ongoing provider coding and documentation audits. Coding and documentation audits are appropriate for all providers, especially highly productive providers who may find themselves under scrutiny for their billings by area Medicare administrative contractors and other payers. Additionally, with future value-based reimbursement models, the importance of accurate and compliant risk adjustment coding is paramount. Our certified coders are available to conduct periodic or ongoing coding and documentation audits to identify claims that have been up-coded, down-coded, included documentation that would have supported additional ICD-10 codes. The audits also involve looking for the appearance of cloning as a result of the use of EHR documentation aides.

Root Cause Analyses (RCA)/Failure, Mode, Effects, and Criticality Analyses (FMECA)

Recent Department of Justice guidance to healthcare organizations reminds organizations of the importance of not only preventing, detecting, and mitigating risk, but asking the “whys” to get to the root of the compliance issue. We can help your organization by leading the key involved departments and individuals through RCA/FMECA analyses and assist your organization in developing/updating policies, procedures, and processes and controls.

Mergers and Acquisitions Compliance Due Diligence

During the compliance due diligence review, our experts review the effectiveness of the seller’s compliance program and evaluates governmental audits and investigations, financial relationships with physicians; compliance with Stark Law exceptions, anti-kickback safe harbors; performs billing and coding reviews, as applicable; and conducts security risk assessments, penetration testing, and vulnerability scans. Ensuring a thorough compliance diligence review at an early stage allows a buyer to address issues promptly, which assures correction prior to close, and to adjust the transaction as necessary.

Contact us today for more information about our healthcare consulting services and learn how we can help your organization.

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