By Kim Woodruff
I had landed my dream job – working as a contract consultant for a company specializing in ambulatory surgery center development and operational management. My first assignment was to stop by a client’s ASC, assess the business office operations, determine if there were any areas of need and outline a 30-day game plan.
The owners of the business were on the fence – they weren’t sure this was a full-time gig, much less something permanent – but they had always been responsive to their staff members’ requests. The operations directors, who handled oversight of the administrative and clinical functions of the facilities, felt the “billing stuff" was beyond their expertise. They already had so much to keep up with – and it seemed to them that it was becoming more complicated as the months progressed. They didn’t know what they didn’t know ... but they were pretty sure there was a vast area of policies, procedures, processes and performance indicators that needed to be addressed. They sensed if they didn’t get their arms around the potential issues quickly, their facilities could be encountering declining profit margins. They had worked too hard to stand back and watch their efforts swirl down the drain.
In the meantime, the Health Insurance Portability and Accountability Act (HIPAA) was taking the healthcare arena by storm. Dealing with the privacy standards had been cumbersome for small businesses with few resources, requiring a significant shift in how healthcare workers conducted their daily business. Before they had time to fully catch their breath, the operations directors were informed that the Administrative Simplification provisions of HIPAA required adoption of national standards for electronic health care transactions and code sets.
It had all become too much. That’s where I came in – I needed to successfully transition each client’s business office from the familiar paper claims submission process to electronic claims transmission. This wasn’t my area of expertise, but my services had been secured to conduct the necessary research, brief the organization on my findings, and implement a viable solution.
In the process, I discovered a myriad of items needing to be addressed – all things that administrators, board members, internal business office staff and clinical employees just didn’t know. These were well-run facilities but the resources and manpower that had historically been employed were no longer sufficient to handle the sweeping changes that were beginning to occur. When presented with my analysis, the owners of the company quickly embraced the need to provide fulltime administrative support to field personnel in order to maintain compliance with the ever-changing environment. Eight years later, I rarely make it through a week without having to explore another regulation or incorporate yet another change into our current practices.
Looking back, it’s amazing we thought it was complicated then because the rules and regulations enacted since that time have multiplied at least three-fold. The trends have continued:
• We are required to do more with less;
• We are recruiting from small or, in some areas, nonexistent applicant pools;
• We have to identify, attract and train the right mix of staff members with the appropriate level of knowledge, experience and expertise;
• We need to retain productive, qualified personnel; and
• We have to maintain uninterrupted work flow when employees are out of the office.
Unfortunately, that’s not where the list stops. We must meet all of the above expectations in an environment that includes, but is certainly not limited to:
• An overwhelming daily onslaught of information
• Constant regulatory changes
• Decreasing reimbursement
• Escalating employee benefit costs
• Drug shortages
• Rising costs during an extended economic downturn
• Increasing organizational accountability and liability
For these reasons, it is important for every ambulatory surgery center to ensure a formal compliance program is in place. If your facility hasn’t tackled this area yet, the time to begin working on it is now. With the passage of the Patient Protection and Affordable Care Act, compliance programs will be required for an expanded number of healthcare providers as referenced in the law’s Subtitle E – Medicare, Medicaid and CHIP Program Integrity Provisions.¹
In Chapter 8 (Sentencing of Organizations), Part B (Remedying Harm from Criminal Conduct, and Effective Compliance and Ethics Programs) of the 2011 Federal Sentencing Guidelines, an effective compliance program means an organization will “(1) exercise due diligence to prevent and detect criminal conduct; and (2) otherwise promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law."²